Tasha McNerney CVT CVPP discusses best practices for anesthesia and pain control in a 0.8lb kitten. These cases are tricky and Tasha lays out why as well as what we can do to reduce the risk and decrease pain and discomfort of our patient.
Tasha and Andy talk through the importance of maintaining cardiac outflow, O2 therapy, blood glucose monitoring, and thermoregulation. Anticholinergics and fasting protocols are also discussed.
This is a FANTASTIC and short episode that is packed with clinical pearls. You won’t want to miss it!
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: http://www.veterinaryanesthesianerds.com/
Dr. Andy Roark Exam Room Communication Tool Box Course: https://drandyroark.com/store/
What’s on my Scrubs?! Card Game: https://drandyroark.com/training-tools/
Dr. Andy Roark Swag: drandyroark.com/shop
All Links: linktr.ee/DrAndyRoark
ABOUT OUR GUEST
Tasha McNerney obtained her CVT in 2005 and has worked clinically in the areas of anesthesia and surgery ever since. Tasha obtained her CVPP (certified veterinary pain practitioner) designation in 2013 and became a veterinary technician specialist in anesthesia in 2015.
Tasha has been a featured speaker on various anesthesia and pain management topics at several international veterinary conferences. Tasha is the author of many articles and blogs on anesthesia and pain management related topics.
In 2013 Tasha created the Facebook group Veterinary Anesthesia Nerds, which has over 65,000 members taking part in education and exchange of ideas from all over the world!
Tasha is crazy and bought a 1920’s fixer upper and is now obsessed with home improvement tutorials on YouTube. She lives in Philadelphia with her husband, son, one perfect cat, and one jerk cat. Trust me that cat is a jerk.
EPISODE TRANSCRIPT
This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.
Dr. Andy Roark:
Welcome, everybody, to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark, back with my good, good friend, the one and only Tasha McNerney. We are talking about anesthesia and analgesia in itty-bitty kitty cats today. This is super fun. It’s really interesting. I think a lot of us don’t think enough about these types of patients, but we certainly see them. What do you do for a cat that weighs less than one pound? Got you covered today. Guys, this is a great episode. Let’s get into 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 back to the podcast. My dear friend, the original anesthesia nerd, the one and only Tasha McNerney. Thanks for being here.
Tasha McNerney:
Thanks for having me again.
Dr. Andy Roark:
Always, always my pleasure. For those who don’t know you, you are a lot of things. You are a wonderful lecturer. You have been the vet tech lecturer of the year at the VMX conference before. I have met you at conferences. Actually, we met in Reno many years ago, and I’ve seen you speak a number of times. You and I have spoken together. We did a Hall & Oates themed track. They gave us a whole track to do something on vet med lessons from Hall & Oates, which I don’t know who signs off on these things, but-
Tasha McNerney:
I know. I don’t know how that got approved when I pitched it, but the fact that they were like, “Yeah, great,” my only regret is that we didn’t do the whole full-on costumes, of you as Oates, me as Hall, and-
Dr. Andy Roark:
I have fake mustache.
Tasha McNerney:
… it could’ve been so good.
Dr. Andy Roark:
I know.
Tasha McNerney:
Listen.
Dr. Andy Roark:
I have a mustache now I could’ve worn.
Tasha McNerney:
I mean, we might need to resurrect this.
Dr. Andy Roark:
Yeah. I agree. So, anyway, we have a history of highs and lows. We’ve made goofy internet videos together. But anyway, you are also a technician specialist in anesthesia, analgesia, and the founder of an enormous Facebook group called The Veterinary Anesthesia Nerds, which also has its own conferences now and things like that. It has really metastasized, if you will, and it’s a force of good in the world. You do great things. Anyway, you are my go-to for in the trenches, on the ground anesthesia, analgesia questions, and I’ve got one for you. Can I ask you about it?
Tasha McNerney:
Of course. Let’s do it.
Dr. Andy Roark:
Okay. This is a case that everybody’s seen, but I just had it. In all honesty, I just had it a week or two ago. So, I got this little black kitten. So, it was about .8 pounds, and it’s just a black domestic shorthair kitty cat, and someone had just found it beside the road, and they brought it in, and they said, “I would like to have this cat and to get it cleaned up and give it a home,” and I said, “I think that’s great, and I want to support that.” As I look at this cat, she has got a big swelling under her right mandible. So, on her neck there’s this big swelling, and I go and I look and there’s a draining tract, and as I squeeze around, I think that there is a cuterebra in there. There is some sort of parasite inside this draining tract. It’s not just infection.
Dr. Andy Roark:
So, I’ve got this itty-bitten kitten, true story, less than one pound, probably four weeks old, and I just am wondering to myself… I don’t want to ruin this cat, fear-free all the way, and it’s sort of like, I want to make sure that I’m keeping this little burger comfortable because this is going to hurt. There’s no way this doesn’t hurt, to have this thing pulled out of your neck, especially if I have to open the tract up a little bit to get to it. So, I just want you to go through with me… Tasha McNerney, talking about a cat this size, anesthesia, analgesia, how do you treat that? Give me some best practices. Help me make sure I’m doing a good job.
Tasha McNerney:
Yeah. So, there’s a lot of things. First off, right off the bat, what I would want to know with this kitten is, especially in the location that you’re telling me, is there any way that we have compromised the airway? We did have a kitten very similar to this come into a practice I relief at, and spoiler alert, you guys, this doesn’t have a great ending, but it had multiple cuterebra, and one of them in the neck area had migrated enough that it had caused a tracheal rupture, and euthanasia was chosen for that kitten just because surgical correction, even with surgical correction and a tracheal stent, might not be… So, again, that’s always going to be in the back of my mind. Has it compromised our airway in any way? If so, we still can work with it.
Dr. Andy Roark:
Thanks for giving me something new to worry about. That had never crossed my mind before, and now I’m like, oh, now I got that to worry about. Thank you for that.
Tasha McNerney:
Well, it’s vet med. There’s always something new to worry about.
Dr. Andy Roark:
Let me tell you something you never even considered that I’ve seen before. Oh, God. All right. Okay. No, I’m onboard.
Tasha McNerney:
All right. So, let’s say-
Dr. Andy Roark:
Note to self.
Tasha McNerney:
Note to self, just make sure that that trachea… Again, you don’t have to go through a full on let’s get a CT, again, unless you’re just feeling really ambitious, but other than that, if you feel like your airway and pulmonary-wise we are okay, all of anesthesia is preparation. I know that a lot of people think that anesthesia is kind of boring in the sense that a lot of these procedures were sitting and monitoring and just writing stuff down. There’s not a lot of movement, fast-paced action. Listen. All of anesthesia is just preparation to make sure that we don’t have fast-paced action once the animal gets onto the table. We want to make sure that we are planning as much as possible, and for a little kitten like this around for weeks old, around a pound in weight, this is really tiny, so we want to plan correctly, and again, a full physical exam as much as we can.
Tasha McNerney:
These little guys are really dependent on heart rate in order to maintain that cardiac output. Remember, we need cardiac output to be maintained because our blood pressure is dependent on cardiac output. So, for these little guys, they kind of come in with that high heart rate. The whole thing during anesthesia is I want to keep that heart rate as close to normal or even a little bit higher as possible because as my heart rate gets lower and lower, or the patient gets bradycardic, that’s going to drop my cardiac output. The reason we care about that is that cardiac output is going to influence oxygen getting delivered to the things that we care about, the liver, the kidneys, the brain, et cetera.
Tasha McNerney:
Also with these guys, the pulmonary reserve is limited, so they can get hypoxic faster. So, these guys, definitely always make sure if you’re giving them any kind of drugs or sedative, it’s in the presence of oxygen, you have supplies ready to go to intubate them. Now, these guys are ones that I’ll tell you sometimes I use them in birds and reptiles, but for these really tiny little guys, I might choose an uncuffed endotracheal tube, an appropriately-fitting uncuffed endotracheal tube, so that way I don’t have to put a tiny tube in and then push that reservoir cuff on the end of a tracheal tube, because too much pressure on these little guys can cause some tissue necrosis in that trachea.
Tasha McNerney:
So, these, I have a selected of not only cuffed, but also uncuffed tubes for them as well. Now, these guys also, everyone’s underdeveloped, so that’s just what you got to on. Their sympathetic nervous system is also underdeveloped. So, that means that drugs that are going to work on the sympathetic nervous system, so again, things like ketamine, telazol, that kind of stuff, those drugs usually will get a sympathetic response, and we see an increase in heart rate and a little bit of increase in cardiac output with them, but we don’t ketamine and tiletamine in these really tiny patients. Again, because that sympathetic nervous system is underdeveloped, they don’t have the same response that an adult or an animal of maturity would have.
Tasha McNerney:
Also, these animals get very hypoglycemic fast. So, before I give any drugs, I want to check a BG and make sure that we’re in range, and I want to be ready to supplement with dextrose as needed. Again, we’re constantly checking EGs. Now, with a cuterebra patient, hopefully they’re not going to be under anesthesia or sedation for a long period of time, but certainly, I have done some amputations on very tiny, tiny little guys where they might be under anesthesia for up to an hour, and we’re every 15 minutes checking BGs on them. Also with these guys, thermoregulation is going to be a big one.
Tasha McNerney:
So, before you get this patient sedation, you want to plan on how are we going to keep them warm, whether that’s a Bair Hugger or whether that is just covering the body in bubble wrap and providing either active or passive warming. You want to have a plan for warming because in these little guys, that larger surface area to body weight ratio means that they’re going to lose heat much faster, and then if you intubate them, you almost always are putting these little guys on a non-rebreather, and remember that that high flow of oxygen from a non-rebreather, it is going to contribute to them getting colder faster as well. So, just be ready with a plan for thermoregulation.
Tasha McNerney:
If you have the opportunity to… If it’s a planned procedure, you know they’re going to come in, again, with the hypoglycemia and et cetera, the fasting recommendations for these guys are no more than three hours, so we want to make sure that they have not been… These are not patients we fast for eight hours or even overnight. We really don’t want to do fasting with these guys. Once we have all of our stuff together, you have your stuff for intubation, you have your oxygen, you know your heat support protocol, all that, if you want to talk about drugs, again, I already mentioned that I probably would stay away from things like ketamine, tiletamine, which is a component of telazol, but maybe I’m going to go with an opioid, and usually the [inaudible 00:10:24] opioids, whatever is your opioid du jour at your clinic, maybe you are a hydro clinic, maybe you are a methadone clinic, again, I always say dealer’s choice when it comes to new opioids.
Tasha McNerney:
I am equal opportunity opioid, so if you want to do hydro or methadone, whatever it is, the nice thing is that it’s reversible, so we just tend to go a little bit lower on our dose, but opioids are pretty safe for these guys. Now, if you give a big dose or you’re giving fentanyl IV, you might see a reduction in heart rate, and again, these guys are really dependent on heart rate, so I always have a dose of anticholinergic drawn up and ready to go for these patients. In some cases, especially in the neonatal, not in this case, but a really tiny brachycephalic patient, because of their high vagal tone, this is the one area of patients where I am going to put glycopyrrolate into their premed to offset any of that reduction in heart rate, and therefore, reduction in cardiac output. So, I always have a dose of anticholinergic.
Tasha McNerney:
Now, some clinics don’t have glycopyrrolate. You might have atropine. So, again, whatever you have at your clinic, just make sure you have a dose of anticholinergic drawn up and ready to go, not over there on a shelf, in the same room with you, but actually calculated, drawn up, ready to go with these. Then the next thing that we consider is if we’re going to put a catheter, if we’re going to intubate them, you can give them an opioid and then a local anesthetic, just a little bit of lidocaine just around the area of the cuterebra to cut those pain signals going to the brain for when you actually have to open and widen it and pop, pull that cuterebra out.
Tasha McNerney:
So, I like a combination of opioids and local anesthetics, definitely some flow by oxygen and ready to intubate as needed. Again, the timing of these procedures, you could make the case that intubation in itself, because it has complications, this might not be warranted, but certainly, if you were dealing with something like an amputation or a longer procedure, you would want to intubate these patients to have control of your airway. If you needed something a little bit more, there’s always alfaxalone, which you could give a small dose of alfaxalone IM. Now, again, with alfaxalone you’re not providing any pain control, and alfaxalone is one of those drugs that if you do use it IM, which is off label in the US, but on label in New Zealand and Australia, if you’re using alfaxalone IM, just remember alfaxalone doesn’t play nice by itself.
Tasha McNerney:
Alfaxalone needs a buddy. It needs a friend. Now, that friend can be an opioid. That friend can be something like midazolam, but alfaxalone doesn’t go well by itself. When we use alfaxalone IM by itself, you tend to see nystagmus, muscle tremors, which some people mistake for seizures, et cetera. So, that’s why I always say make sure if you’re giving alfaxalone, you’re pairing it with something else, and in this case we would be. We’d be giving this kitten an opioid of some sort. Does that all sound good?
Dr. Andy Roark:
That all sounds good. So, there’s a lot there. That all matches up. I’m frantically taking notes over here. Yeah, that’s really helpful.
Dr. Andy Roark:
Hey, everybody. I’m just jumping in with two lightning-fast updates. Number one, if you have not gotten signed up for the Get Sh*t Done Shorthanded Virtual Conference in October, it’s October 6th through the 8th, you need to do that. If you are feeling overwhelmed in your practice and you want things to go smoother and faster, if you do not want to watch webinars, you want to actually talk about your practice. You want to do some discussion groups, you want to do some workshops where you actually make things and work on things and ask questions as we go along, and have round table discussions and things like that, that’s really going to energize you and help you figure out actionable solutions that you can immediately put into practice to make your life simpler and more relaxed, I got you covered, buddy, but you don’t want to miss it.
Dr. Andy Roark:
Go ahead and get registered. Mark yourself off at the clinic for the time so that you can be here and be present and really take advantage of this. I don’t want it to sneak up on you. I know October seems like a long way away. It’s not. But go ahead. I’m going to put a link down below, and then when registration opens, we’ll let you know it’s open and you can grab your spot. But you do not want it to sneak up on you. Check out our Get Sh*t Done Shorthanded Conference. It’s going to be a great one. The second thing I’m going to tall you about is Banfield. Thank you to Banfield Pet Hospital for making transcripts of this podcast available. You can you find them at drandyroark.com. They are totally free and open to the public, and Banfield supports this to increase accessibility and inclusion in our profession. It’s a wonderful thing that they do. Guys, that’s all I got. Let’s get back into this episode.
Dr. Andy Roark:
Do you have a thermoregulation preference for an itty-bitty like this? Is there something that you think is more effective with something so tiny? I imagine this little speck disappearing underneath a Bair Hugger. You’re kind of hovering over top of the kitten because there’s just so little there. Yeah. Do you have… Give me some advice. Even if it’s just… You said dealer’s choice. Even if it’s personal preference, what do you like for helping maintain body temperature in itty-bitties?
Tasha McNerney:
Yeah. These really tiny ones, I do still think that an active warming as a HotDog or a Bair Hugger or a warm water blanket is the way to go.
Dr. Andy Roark:
Okay.
Tasha McNerney:
Certainly, as you said, we can’t use a regular… Even the small size Bair Hugger blanket this kitten is going to disappear under, but we can… A lot of people, if you have Bair Hugger blankets in your practice, they come with these little plastic inserts, and most of the time people just throw them away. I’m going to tell you, don’t throw them away. Okay? You can actually use the plastic sticky things that come in with it. They come with the Bair Hugger so that you can put the plastic around, and they actually help to seal in the juices as far as the heat goes. But again, most people just throw them away. Don’t. Keep them around because you can stick them longways over your patient, and then you can just finesse the Bair Hugger output or the warm air output underneath this plastic.
Tasha McNerney:
Again, you could use something like bubble wrap as well, and then provide the Bair Hugger underneath that. But usually, I have it on each side. So, I might have a warm water blanket, warm water circulating blanket underneath the patient, and then I might have the Bair Hugger or even a HotDog around it. I will say I’m a fan of the HotDog. What I like about it is that unlike the Bair Hugger, you don’t have to worry about things blowing around your surgical site, and the nice thing is for these really tiny patients, the HotDog does actually make a very tiny size HotDog blanket. It is adorable if you have the chance to see it, but it’s made for hamsters and gerbils, so it’s really tiny, and it will wrap around the patient to provide active warming. So, if you have a HotDog in your practice already and you are dealing with small cats and kittens, I would say invest in one of these because it is really nice to wrap them around, and again, it’s just freaking cute.
Dr. Andy Roark:
All right. I feel good about that. So, I’m feeling good about all of this, honestly. So, up to our procedure, this all makes sense. I can lay all this stuff down. I have everything in the clinic. This is perfect. This is really, really great. Do you have any advice on analgesia post-procedure?
Tasha McNerney:
Yeah. So, for these guys, analgesia post-procedure, hopefully… Here’s the thing. Unfortunately, what you’re going to be dealing with is some inflammation, and we just don’t have, or at least I would say that I would be a little bit uncomfortable giving something that’s four weeks of age a nonsteroidal antiinflammatory. So, with this patient you could consider things like oral transmucosal buprenorphine for analgesia. If you have gabapentin formulated, please note that I’m not saying that gabapentin will be the sole analgesic, but gabapentin can help these patients feel better, provide a little bit of sedation, et cetera. Also, for inflammation, if you have in your practice and you are able to do a session or two before the patient leaves, something like a low-level laser therapy on the antiinflammatory setting is a nice, again, non-pharma adjunct for these patients.
Tasha McNerney:
But really, cats are just amazing in how fast they can bounce back. I think the biggest thing with these little guys is that as long as you’re maintaining their heart rate and their cardiac output, again, which you know what, just means no dexmedetomidine. I know you’re all tempted, and it’s my favorite drug, but in these guys we want to make sure we avoid dexmedetomidine or something like that. But for post, usually these heal up pretty quickly. I like to do laser therapy gabapentin if you can get it compounded so that your dosing would be accurate. It’d be hard to give this little tiny kitten a tablet or a quarter or an eighth of a tablet.
Dr. Andy Roark:
Yeah, yeah. At some point, you’re just kind of scraping powder. Yeah.
Tasha McNerney:
Yes.
Dr. Andy Roark:
That’s no good. All right, perfect. Man, that’s super great. Tasha McNerney, you are amazing. Thank you so, so, so much for being here. Where can people find you online? Where can they learn more if they like to geek out about anesthesia?
Tasha McNerney:
Yeah. So, if you are on Facebook, we run the Veterinary Anesthesia Nerds Facebook group. I always tell people that if you’re not on Facebook, this is not the reason to get on Facebook. If you’ve avoided Facebook this long, I applaud you. You’re probably living the life, man. So, we are on Facebook. We also are going to be having a conference within a conference this year. So, if you are going to or if you’re thinking about heading to Fetch in San Diego in December, the anesthesia nerds are going to be running their conference inside of the Fetch Conference. So, we’re going to have two days of nothing but anesthesia and pain management. We’re doing a regional nerve block wet lab to teach people some more advance ultrasound-guided regional nerve block techniques, and we’re going to do basic nerve blocks as well, but all things nerve block. So, that’s going to be coming out, our links to register for that, pretty soon.
Dr. Andy Roark:
That’s outstanding. Awesome, awesome. Thanks anything for being here. Guys, take care of yourselves. Have a wonderful week, and I’ll talk to you next week.
Tasha McNerney:
Thanks.
Dr. Andy Roark:
That’s our show. That’s what I got for you, gang. I hope you enjoyed it. I hope you got something out of it. If you’re watching on YouTube, hit that subscribe button. If you are listening on the podcast, leave us a review wherever you get podcasts. Tell your friends. That’s how people find out about the show. I really appreciate it. Really appreciate your help. Gang, take care of yourselves. I’ll talk to you soon.
