Tasha McNerney, CVT, VTS (Anesthesia & Analgesia), aka the original Anesthesia Nerd, joins Dr. Andy Roark to dive into the cutting edge of pain management in veterinary surgery. In this episode, Tasha discusses how to reduce opioid use while improving patient outcomes through multimodal analgesia and local anesthetic blocks. She breaks down the ERAS (Enhanced Recovery After Surgery) protocol, adapted from human medicine, and how it can revolutionize the way veterinary teams manage surgical pain.
Dr. Roark and Tasha explore practical strategies for implementing local blocks in a variety of procedures, from spays and neuters to advanced orthopedic surgeries, and discuss how adjunctive analgesics like ketamine and dexmedetomidine can enhance outcomes. Tasha also shares her vision for the future of veterinary surgery, emphasizing the importance of technician training, low-stress handling, and better pre-visit pharmaceutical protocols. Get ready to elevate your pain management game. Let’s get into this episode!
You can also listen to this episode on Apple Podcasts, Amazon Music, Spotify, YouTube or wherever you get your podcasts!
LINKS
Pre-order Pain Management for Vet Techs and Nurses on Amazon
Veterinary Anesthesia Nerds website
Dr. Andy Roark Charming the Angry Client Team Training Course
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
Dr. Andy Roark: Welcome everybody to the Cone of Shame veterinary podcast. I am your host, Dr. Andy Roark. Guys, I got a fantastic one for you today. I am here with the one and only Tasha McNerney, aka the original anesthesia nerd. And we’re talking about reducing opioid use in our surgeries and upping our game with local analgesia.
This is a really good conversation. We get down in the weeds about, how do you actually do this, Tasha? I just, I’m very open in this about concerns that I have about just going wild with locals and decreasing opioids. And we just, we really get into it. Anyway, if you do surgery, if you do pain management, I think you’re going to get a lot out of this episode.
It is really really good. I talked to Tasha about her new book pain management for vet techs and nurses. She’s the editor of this book. I don’t want to take away from any of the people who are writing chapters. They look phenomenal, guys. I can’t wait to get my hands on a copy of this. So anyway, that’s what we’re talking about today. Let’s talk about local anesthetics analgesics and let’s get into this!
Kelsey Beth Carpenter: 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, my friend?
Tasha McNerney: I’m doing well. Thank you.
Dr. Andy Roark: I am so glad to have you here. I always love getting to hang out with you. You have been on the podcast many, many times. The last time I saw you, you were here in Greenville.
We were going to a wedding together. We got to spend a weekend hanging out with your family and it was absolutely joyful. We did not make any podcasts. I was like, we have to remedy that. And so now we’re back. You have a new book coming out. And I was like, look, I dropped the ball at the wedding, but now she has a book coming out.
Like I have got to get
Tasha McNerney: Yeah, man. Why were you not, why were we not talking about my book coming out at someone else’s
Dr. Andy Roark: Someone else’s— yeah, exactly.
Tasha McNerney: What is the day about them?
Dr. Andy Roark: Look, your self promotion game is weak sauce.
Tasha McNerney: It’s terrible. I know it really is. Yeah.
Dr. Andy Roark: You really need to up.. Actually, no, it is. It’s terrible. For people who don’t know you, you, I said, I said, okay, what is your official title? And you said, I am a co administrator at Veterinary Anesthesia Nerds, which I said, it sounds like you answered a newspaper ad to get that job.
You are the founder. You, it was your brainchild to create the Anesthesia Nerds. You, you have wonderful partners that you work with who do, I know you’re so humble, but they have done so much work with your team to make this thing happen and to make it awesome. If you guys don’t know what I’m talking about as far as Anesthesia Nerds, you need to check out their new website.
It’s beautiful. Their Facebook group has been around for a long time, but if you’re interested in anesthesia and pain management and you’re not that anesthesia nerds, I really think you’re missing something that’s going to make you really happy. And so anyway, you and I met, we met in Reno and you were just getting anesthesia started.
And so anyway, that’s enough about us. I, I am gonna, we’re gonna talk more about your book in a bit. It’s Pain Management for Vet Techs and Nurses, which is available for pre order on Amazon. But I wanted to talk to you about something that you’re out and you’re talking about these days. And it is, it’s, you’re talking about the ERAS protocol and you’re talking about local blocks.
And so, first of all, let’s just start with the ERAS protocol and walk me through, what is, what is that?
Tasha McNerney: Yes, if anybody has heard me speak probably in the last six months, they know that I’m kind of obsessed with ERAS, and inevitably,
Dr. Andy Roark: Swift album.
Tasha McNerney: No, well, listen, I’m a Swiftie. I think that probably if anybody looks through the archives of our podcast together I’m We do have a podcast where our, for Halloween, I was, I did record with you on Halloween.
I was dressed as Taylor Swift in the cheerleading Taylor Swift for you guys who knew the Taylor Swift the discography and the legend out there. You know what video I’m talking about, but anyway. In the theme of ERAS, no, we’re not talking necessarily about Taylor Swift. What I’m talking about with ERAS is something called Enhanced Recovery After Surgery.
And this comes from human medicine and it has been around for quite a bit in human medicine. They actually started a group within the anesthesia society in human medicine all the way back in I believe it was 2016 or 2017. Researchers started looking at ways they could minimize opioids, right? So reduce opioid use while still ensuring patients had a high level of pain relief
and then also putting in other things into the protocols to ensure that these patients were up and moving faster and just had a greater overall, better enhanced recovery after surgery.
Dr. Andy Roark: So when you start looking at this, okay, you’re looking at that medicine and traditionally that medicine was pretty opioid heavy. It’s a big part of our pre medications things like that when you were thinking about ERAS protocol and you were thinking about how vet medicine, especially anesthesia and analgesia have been traditionally applied, what do you start to see?
What are you what sort of changes do you think will do the most good in vet practices. And, and, and, and what does that look like?
Tasha McNerney: Yeah. So one of the key pillars, and there’s a, there’s a couple of different things that go into ERAS protocols in human medicine that we can take over into veterinary medicine. But one of the main things, kind of number one is, to be opioid sparing and to use what’s called multimodal protocols. Now, probably if you’ve ever been to any anesthesia lecture in the past 10 years, you’ve heard about multimodal protocols.
You probably already using multimodal protocols in your practices. However, what I’m finding is that these multimodal protocols, when they talk about them in the context of ERAS in human medicine, multimodal protocol always, always, always includes regional anesthesia or a local block whereas that’s something that I do think in veterinary medicine We could get a lot better at.
Dr. Andy Roark: When we start talking about sort of local blocks, and you have talked about this, I’ve had you on many, many times to talk about all different kinds of sort of local blocks and things like that. Are you, are you basically saying I don’t want to oversimplify this, but should I be questioning myself if I’m starting to do any sort of soft tissue surgery and not be using a local?
I mean, is that, is that kind of where we are? It’s basically, if I’m not using a local, I should stop and ask myself, why am I not using a local? And how do I need to use a local in the surgery? Are we at that level?
Tasha McNerney: Yes. We are at that level one of the key things with ERAS and kind of what I teach when I go out and start talking to people about how to build a good multimodal protocol Is you know kind of like when you’re building that protocol and you’re looking at that that procedure in front of you. Let’s say it’s a spay, just for instance, right?
So we, you’re always kind of thinking, okay, well, what opioid am I going to use for this spay? What non steroidal am I going to give for this spay? What induction agent might I choose? Now, I want you to also think, what local block could I use for this procedure? Again, whether it’s a laceration repair, whether it’s a spay procedure, whether it’s a dentistry, there is a local block that we can use for almost every single procedure that we perform in veterinary medicine.
Dr. Andy Roark: Let’s say that I am your average small animal veterinarian. I do not have a local block for every procedure that I do. But I’m hearing you and I’m like I, I want to be better. How do I start to build multimodal protocols that make sense? How do I get that education? Yeah, help me, help me start to tomorrow do better for my patients.
Tasha McNerney: Yeah, so there’s a lot of first off, there’s a lot of information online. I mean, certainly, our Veterinary Anesthesia Nerds website has a lot of blogs and resources that you can look at within our new pain management book. We talk about ways to do multimodal protocols and how, you know, we have a whole chapter just on all of the different local blocks that you could do.
And you’re totally right. There’s, there’s all kinds of levels out there, right? We could be talking about something very simple, like an infiltration block or what we usually call a line block, or even a splash block. Or if you really want to get fancy with your training and you want to kind of do that gold level medicine, you can, you and your staff can go get trained in ultrasound guided nerve blocks, which is kind of like, as far as that’s pretty cool, right?
That’s some stuff that they’re doing a lot in human medicine that we’re starting to follow now in veterinary medicine. It doesn’t have to be that you have to go all that way, right? If you are a general practice and you’re like, my bread and butter is just some spays, neuters, maybe some lumpectomies and some dentistries, there are plenty of local blocks that you can incorporate into those procedures that do not necessarily take a huge amount of extra training and you don’t need to do like ultrasound guided, right?
We can do dentistry blocks for patients just going on landmarks, same for infiltrative blocks where we are just infusing the subcutaneous space along each side of the incision with local anesthetic.
Dr. Andy Roark: So I imagine people hearing this and getting really excited, and they’re just in surgery with a big, like, 30cc syringe of lidocaine, and they’re just, like, blocking this. You get a block, and you get a block, and you get a block. Okay, what constitutes a good block versus nonsense? Mm hmm. Mm hmm.
Tasha McNerney: There’s a couple of different studies out there, right? So certainly a really good block is one that if you have the ability to do it, ultrasound guided or nerve stimulator guided, where you can make sure that you are actually depositing the local anesthesia in and around that nerve or bundle of nerves to prevent that signal transmission from going forward, kind of like with an epidural, right?
That’s kind of like the top of the line, right?
Dr. Andy Roark: Mmm-Hmm.
Tasha McNerney: However, we have these peripheral pain receptors all over. So, even if you can and you do the splash block technique or an interperitoneal technique, you are still going to get some coverage and some efficacy. And again, any coverage or efficacy is just going to help contribute to you or your patient, meaning less overall opioids in the post operative period, and intraoperatively, meaning less gas anesthesia.
So anytime that we can do a multimodal protocol and rely less on that. on gas anesthesia. That’s going to be better for our blood pressure. That’s going to be better for cardiac output and similar to opioids, right? If we can do more of these multimodal techniques, more local blocks to cover, like we want the local blocks to be the heavy hitters for pain, not necessarily large amounts of opioids because large amounts of opioids come with challenges as well, right?
These patients wake up, they’re kind of nauseous. For some patients, we have to worry about the decrease in heart rate or cardiac output if we have a monofentanyl CRI or something like that. We have to worry about changes in their thermodynamics when they’re on opioids. And we have to worry about, like, opioid dysphoria in the postoperative period.
So anytime we can minimize opioids and kind of ramp up with other things, again, local blocks being a key component to that, it’s going to give the patient an overall better experience. And we have some studies to show that not only are they up and eating faster, but they’re discharged from the hospital faster and the owners have overall greater satisfaction.
Dr. Andy Roark: so I want to come back to that, overall satisfaction in eating faster and things like that. At the moment, Tasha, like, How do you know this is working? Right? You’re, you’re a new vet and you’re like, I’m gonna start, I’m gonna start doing this. Yeah. How, how do I know? How do I know that I’m making an impact?
How do I know that I, that my blocks are actually accomplishing things? You know, I, I’m assuming in human medicine there’s a pain score and you ask the person, you know, what was your pain score and what’s your recovery score? And things like that. We don’t, we don’t really get that level of insight. How, how do you, how do you know that you’re, that you’re doing it right?
Tasha McNerney: Yeah, well, the nice thing is that we do have pain scoring. We have a lot of different ways that we can pain score post operatively for acute pain. Now, you can utilize something as It’s as simple as the University of Colorado scale, which is available as a free download and a PDF that you can print out and put around your hospital and train your staff on.
Or if you want to get a little more advanced and you want to utilize something that has been validated and researched, you can utilize either the Glasgow short form pain scale, or you can do, you know, if you have felines and you’re doing a feline heavy practice utilizing the feline grimace scale, which has also been validated and is very easy to use.
and has a pretty handy app online as well for pain scoring, acute pain in cats, which works wonderful post surgically. And we have been able to see that patients who get local blocks, either, you know, are post TPLO patients that before we may have had them on fentanyl CRIs for 24 hours post knee surgery.
Now with targeted local blocks, we maybe have them on a couple, one or two doses of an opioid post op instead of up to 24 hours. So we’re, again, we are seeing it in real time utilizing these pain scoring methods that animals that do get these local blocks tend to need less rescue analgesia and have greater, better overall pain scores in the post operative period.
Dr. Andy Roark: What’s your favorite pain score and why?
Tasha McNerney: Oh my gosh, it’s like my favorite child. All right. So, so I think the Helsinki index is really, really interesting one. But again, it’s, it takes a longer amount of time. So I don’t know if it is practical. So really from a practicality standpoint, an acute pain score that every single practice can implement tomorrow.
That’s the feline grimace scale. Like the, the researchers in Montreal have outdone themselves with all the work they have put into that project and, you know, understanding feline acute pain and it’s, it’s chef’s kiss to them.
Dr. Andy Roark: I agree, the app is so cool, and like, yeah, it’s just, yeah, anyway, alright, alright, just curious. Alright, great. Talk to me about reduction of opioids. So, I would like to use less opioids and I’m doing these blocks. How do I start to titrate down my opioids so I’m not having a panic attack the first time?
You know, I’m, I’m imagining that we’re probably not taking a certain percentage reduction, but talk to me about how you would work with a vet who’s starting to use local blocks and things and start to actually turn that dial down in a way that everybody in the room is going to be comfortable with.
Tasha McNerney: Yeah, so I also want to clarify just to make sure that people know that I am not talking about opioid free protocols. There was some research into opioid free protocols in veterinary medicine and they did not in the one study that was out they didn’t find a huge benefit to going completely opioid free.
So I just want everybody to know I’m not talking about opioid free or never using opioids. What we’re talking about is just reducing opioids or being what they call opioid sparing Okay we still want to use opioids, right? Because opioids are going to work on our, when we think about the different pain pathways that our analgesics are working on, those opioids are going to work on modulation of those pain signals.
They are going to work on patient perception of pain. So opioids are still an important component of your multimodal protocol. What we want to get away from though is just putting every single abdominal surgery on a CRI of fentanyl, or every single orthopedic on a CRI of fentanyl.
When we have these targeted local blocks together with adjunctive analgesics, which we can talk about in a minute when we’re utilizing these things together, right, we’re utilizing multiple drug classes, to get the maximum amount of analgesia with the minimum amount of side effects. Because instead of just giving one whopping dose of fentanyl and then continuing with a fentanyl CRI, which is going to be problematic in its own right, we still want to use a little bit of fentanyl, but we also want to add in maybe a little bit of dexmedetomidine, maybe a little bit of ketamine, and our local blocks in there, and then we can keep our inhalant really low.
So it’s all about that kind of balance, instead of just a sledgehammer of opioids, which I think that we have just been so dependent on opioids being our heavy hitter for pain. And again, this is not to trash opioids, but you guys, the more we start reading about some of the studies that are coming out in human medicine and how they are able to achieve really excellent analgesia without opioids, it’s pretty fascinating.
Dr. Andy Roark: Yeah. No. So talk to me about adjunctive analgesia then.
Tasha McNerney: All right. So I actually kind of first started this kind of in my brain of looking at like, Hmm, could we be doing things better? Because I’ll tell you, I am a CVPP, which is a designation given out by the IVAPM, which means that I’m a Certified Veterinary Pain Practitioner, which means I just love and have spent a lot of time researching and studying all things pain management, right?
I got invited to go speak at a conference in Moscow and I went over to Moscow and it was very, very cool. The people there were wonderful. They were so into kind of like, what are some things that you’re doing in America that we could be doing better here, etc. I got to spend a half day at one of their veterinary clinics.
And one thing that really stood out is that a lot of their surgeries, had epidural catheters placed, and Andy, an epidural catheter is a pretty advanced procedure, and these were, these were GPs, like a GP, and every every one of their doctors and nurses on staff was proficient in these advanced local blocks, and so I started asking, and it turns out that their opioids are not approved for use in veterinary medicine.
So they have to adapt and they have to try to do good analgesia without opioids at all. Now again, that’s not what I’m advocating for here But as I started to think is that something that we should be doing or could be doing and then I started doing all this reading. Yes, actually minimizing opioids and utilizing other analgesic adjuncts, right?
So in human medicine, they use a lot of acetaminophen. And right now acetaminophen is kind of a hot topic for veterinary medicine as well. Please note everyone, I’m not saying that for feline patients, but in our veterinary canine patients, we are looking at utilizing Acetaminophen or paracetamol, if you’re in the UK, a lot for its additional analgesic benefits.
It’s a nice analgesic adjunct. The same thing with ketamine. For a while we kind of thought of ketamine as kind of this older drug, right? And had a lot of, when you use ketamine at high doses, it’s in a dissociative. So cats on high doses of ketamine, It’s usually not a fun time. But what we found is that micro doses of ketamine working at that NMDA receptor actually functioned really nicely as an analgesic adjunct.
Same thing with dexmedetomidine. Now, you know I love my dexmedetomidine. Fantastic drug. And when we looked at the way that it functions as an analgesic, again, none of these drugs, ketamine or acetaminophen or amantadine or anything like that, they’re not going to be strong enough to kind of handle an abdominal surgery and orthopedic surgery on their own.
That’s why the multimodal protocols are so important. And when we talk about creating a really great multimodal protocol for one of your patients, again, whether it be a spay, whether it be an orthopedic procedure or a dentistry procedure. I want you to think about the following things. What opioid should I utilize?
What opioid is going to make the most sense for this patient? What adjunct should I utilize? Now again, your adjunct could be something like ketamine, it could be something like dexminutominine, it could be something like midazolam, but remember we’re not utilizing midazolam for its analgesic properties.
So what is your adjunct going to be? And then what is my local block for this procedure going to be? So you should be able to answer all those three questions. Depending on the patient’s ASA status or what other things they have going on health wise, the anticipated level of pain, those answers really shouldn’t be the same for every single procedure.
Sometimes they might, but we want to make sure that we are treating each patient as an individual and each procedure kind of as an individual item that we are looking at. What is going to be the opioid that really makes the most sense for this patient? And sometimes it might be fentanyl. But you know what?
Sometimes it might be buprenorphine. So what other adjuncts can I add? And then what local block is going to work the best for this patient?
Dr. Andy Roark: Okay. Let’s, let’s time travel together. So let, let’s jump, let’s jump in my time machine. We’re going to go ahead five years. So we’re looking at 2030. Tell me about what you see the surgery prep area looking like and how people are behaving there five years. That’s different from how it is today.
Tasha McNerney: I think that probably five years where we’re going to be at is going to be that our technicians especially our VTS level technicians are hopefully going to be utilized even more. And they are going to be kind of crack a lock and when it comes to these local blocks. I’ve kind of made it a personal mission to make sure that every technician that I work with, or that I train at one of, you know, our veterinary anesthesia nerds events.
gets trained in advanced local blocks and kind of these advanced procedures. And I think that is going to be the future in the same way that your technicians are going to be drawing up propofol for your procedure. They’re going to be executing on a local block for your procedure. And I do think we are going to see even better succinct use of pre visit pharmaceuticals.
And you know, for patients that are fearful, I do think that, you know, for a while, as everybody knows, we kind of talked about it in Anesthesia Nerds, we were just throwing gabapentin at everything, and then maybe throwing trazodone. And I think as we start to see how those drugs play in, again, great drugs, but I do think there are other drugs kind of out there as well that we could be utilizing from a behavior standpoint, a low stress standpoint.
I think that we’re also going to start to see patients and our technicians getting trained in more low stress handling so that overall five years from now when a patient comes in from for surgery it’s just going to be as smooth and as calm and as pain free as possible.
Dr. Andy Roark: Sounds fantastic. That makes me super happy. I really, really love it. Tasha McNerney, you are the author of Pain Management for Vet Techs and Nurses. It is available for pre-order on Amazon. Where can people find you online?
Tasha McNerney: Yeah, so head up the Veterinary Anesthesia Nerds website. We actually just redid our website. We posted a whole bunch of blogs on there about anesthetic oxygen flow, about when and where you, and how you should clean your anesthesia rebreathing bags, about vaporizer output, about time constants and dead space.
We also have a link to our new YouTube channel, which gives different videos on how you can leak test your anesthesia machine, how to leak test a non rebreather, how capnography works, all kinds of stuff.
Dr. Andy Roark: That’s fantastic. I love the work that you do, Tasha. You make such a difference for people. You’re such a wonderful advocate and example for technicians. I just, I love the way you think. You are such an outstanding teacher. Thanks so much for being here. Thanks for being my friend. I just love having you around.
Tasha McNerney: Yeah, let’s go to more weddings together.
Dr. Andy Roark: Let’s do more weddings together. Alright!
And that’s what we got guys, I hope you enjoyed it. I hope you got something out of it. Thank you so much to Tasha for being here because she’s such a wonderful presenter. She is such a wealth of knowledge that I just fill out pages of notes every time I talk to her because her ability just to lay out information and make it simple and make it understandable and use metaphors and tell stories and give examples just just phenomenal.
I just think she’s such an incredible teacher. So anyway, thanks to Tasha. Thanks to you guys for being here. Take care of yourselves, everybody. We’ll see you, we’ll see you later on.
