Tasha McNerney CTV VTS CVPP joins us to discuss the case of Hercules Mulligan. a 4 yo MN Domestic Shorthair who cannot urinate. That’s right… This poor guy has a urethral obstruction and will need anesthesia and pain control STAT! What are the top tips and tricks for handling these cases? What mistakes do doctors and technicians want to make sure to avoid? Let’s find out!
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LINKS
Sacrococcygeal Block Demo: https://www.youtube.com/watch?v=KhAN4SavVzg
Think Anesthesia: https://www.thinkanesthesia.education/
Retain Your Team – Speak the Languages of Appreciation in Your Workplace: https://unchartedvet.com/product/appreciation-languages-101/
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’m your host, Dr. Andy Roark. Guys, I am here today with the original anesthesia nerd, the one and only, Tasha McNerney, and she is fantastic as usual. We are talking about the blocked cat and running effective anesthesia and pain control in those emergency cases. Guys, we see a lot of these in the vet clinic. They are an emergency, and we want to do right by our patients as far as making them as comfortable as possible, while we do uncomfortable things to save their life. Gang, let’s get into this episode.
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, the one and only, Tasha McNerney. How are you?
Tasha McNerney:
I’m good. How are you? How is everything?
Dr. Andy Roark:
Things are good. Rolling into the spring. Yeah, exciting times around here. Getting close to the summer break. The kids are starting to make plans for what they’re going to do this summer. I got a load of mulch from my garden and that makes me happy. So, that’s-
Tasha McNerney:
You know-
Dr. Andy Roark:
[crosstalk 00:01:29].
Tasha McNerney:
You’re an adult when you’re excited about mulch, right?
Dr. Andy Roark:
Oh, yeah.
Tasha McNerney:
And then, you’re like, “What type of mulch? Are you a red mulch person? Are you a brown mulch person?”
Dr. Andy Roark:
Oh, it’s-
Tasha McNerney:
“Are you a black mulch person?”
Dr. Andy Roark:
It’s brown mulch, yeah.
Tasha McNerney:
Okay, yeah. So…
Dr. Andy Roark:
It’s the double brown mulch. Yeah, it is. Yeah, the hummingbirds will be back soon. And that is where I am in my life.
Tasha McNerney:
I mean, listen, my husband is out there feeding the birds every morning and he is very concerned about the birds. He likes to watch the birds. He likes to tell me how many birds are in the backyard, whether or not there’s a chipmunk with the birds, if he saw a rabbit outside. These are the things that we get excited about now, right? Yeah.
Dr. Andy Roark:
Yeah. You married-
Tasha McNerney:
[crosstalk 00:02:09].
Dr. Andy Roark:
The cat.
Tasha McNerney:
Yeah, I did. I did marry a crazy cat lady and that’s totally fine.
Dr. Andy Roark:
Oh, god.
Tasha McNerney:
I love him. But yeah, he’s excited about birds, and choosing a high quality bird seed is very important. And we used to be cool. We used to go out on Saturday nights. And now, we’re like, “Um, so Righteous Gemstones and researching bird feeder option?” “Yes.” That’s a Saturday night.
Dr. Andy Roark:
Yeah. Okay, we need to spend more time together because one, Righteous Gemstones for the win. I love that-
Tasha McNerney:
Oh, 100%.
Dr. Andy Roark:
It’s a guilty pleasure show. I love that show. And then number two, this was the first time in my life I have ever walked into a Lowe’s and looked at the different bird seeds and thought, “Ugh, who would feed that?” I never had a thought like that in my life. I’m like, “What has the pandemic done to me? It has made me…” I’m like, “Ooh, this is the cheap stuff. I’m not feeding this.” What have I become? Good God. All right, let’s ride this show. Let’s talk about other things besides bird seed and Righteous Gemstone. Let’s talk about blocked cats.
Tasha McNerney:
Yeah.
Dr. Andy Roark:
The other part of the trifecta of things that are super cool. All right. I have a case. Tasha, first of all, for those of you who don’t know, you are the founder of Veterinary Anesthesia Nerds, which is a Facebook group and also a conference now and so many things. For anyone who’s interested in anesthesia, you should really check out Veterinary Anesthesia Nerds. What is the best place for people to find information on that group?
Tasha McNerney:
So our Facebook group is probably where we are the most active, where we talk about cases every day and run through cases, equipment, et cetera. We also have a website that you guys can check out. And then, we have since partnered with dvm360. So a lot of our content and articles from the administrators, myself, Stephen Cital, Darci Palmer, all VTS in anesthesia, we have a lot of articles on dvm360 that you can find there as well for different anesthesia topics.
Dr. Andy Roark:
That’s awesome. All right, cool. I’m going to toss you a softball today because I just-
Tasha McNerney:
Oh, great.
Dr. Andy Roark:
Want to make sure that I am up on my game. Yeah. I just want to make sure that I’m doing all right. It’s one of those questions just [inaudible 00:04:18] make sure that nothing has changed in how I’m doing this. Make sure that I’ve got all the pearls that I need to do a really good job. I have a four year old male, neutered, domestic short hair named Hercules Mulligan and he is obstructed. He’s come in, he was straining in the litter box. His owners who are huge Hamilton fans brought him in and they were like… He’s crying. He’s in the litter box.
Dr. Andy Roark:
I feel his belly. I know immediately what’s going on. This guy is obstructed. I’ve pulled some blood on him. I’m checking my electrolyte levels, making sure that nothing is super wonky there, and he seems to be okay. Aside from starting IV fluids, things like that, I need to go ahead and get this cat unblocked, and I don’t want this to hurt. And I also want to get him pliable and easy to work with. And so again, he is an otherwise healthy, young to middle aged male cat. Help me with my anesthesia, analgesia protocol here, so that he is comfortable and I can do what I need to do as quickly as possible.
Tasha McNerney:
Sure. So first of all, anesthesia, I mean, it’s definitely about drugs, but it’s not all about drugs. And we know with some of the more kind of progressive ways, at least in the last 10 years and what I have seen and probably you’ve seen in practice as well, is that we don’t just go into drugs. We want to take stock of kind of where the patient is at, kind of where with their own fear and anxiety. So how scared is the cat, right? So, how upset is he with being at the vet? How fearful is he? How reactive is he? And that is really going to play a lot into what I do next. If he is very fearful-
Dr. Andy Roark:
Okay, I like this a lot.
Tasha McNerney:
If he is very fearful and painful, then I’m probably going to go with some IM sedation. I don’t want to take this cat that is potentially again, very fearful, very painful obviously… If anyone here has ever went on a very long car ride and had just an overextended bladder that’s getting very uncomfortable, if you think about that times 10, this is what our patients are experiencing. So, very uncomfortable. I don’t want to take that patient and then have to have our support staff kind of sit on or muzzle or wrestle with this cat to try to get an IV catheter into them.
Dr. Andy Roark:
Right.
Tasha McNerney:
Stress is going to be the enemy for these patients. I mean, any cat that potentially has any underlying cardiac issue, with potentially a hyperkalemic patient as this, we don’t want to stress them. So, stress is our enemy. So, let’s take stock. If he is a super love bug cat, and he is going to let me put an IV catheter in and facilitate that without an IM injection or IM sedation, great. And then, we can follow up with some IV analgesics, anesthetics, et cetera. But if he is saying, “No, you guys. I’ve had enough. I’ve already had a crap day. I don’t feel good. You’re not going to twist my arm to put an IV catheter in. No,” then-
Dr. Andy Roark:
Right.
Tasha McNerney:
I’m probably going to sedate. And I love this option because just sedate the cat, right? Just give them drugs. We have lots of great drug options that we can give them. And first off, we want to look at our analgesics. Certainly, if you have a pure mu-opioid in your practice, my favorite is methadone. But if you guys have hydro, you could consider hydro. Now, just remember, you might see some vomiting with the hydro, but if that’s your heaviest hitter, go with that. I like a methadone combination. Again, if you don’t have methadone and you’re like, “Oh man, I only have butorphanol,” okay. Even though that’s more of a sedative than an analgesic, go with that. So, we want to combine an analgesic with a sedative.
Tasha McNerney:
Now sometimes, as people know and if they’ve ever listened to me talk, they know that one of my favorite sedative analgesic combinations is opioid plus dexmedetomidine. This is not the patient I would probably choose for dexmedetomidine because again, we don’t know exactly… Unless you’ve taken blood and evaluated his potassium levels, we don’t know where that’s at. I don’t know if he’s hyperkalemic and bradycardic and potentially already having some arrhythmias because of the urethra obstruction.
Dr. Andy Roark:
Got it.
Tasha McNerney:
So, let’s just assume maybe he is and I just want to be very careful. So I’m going to take dexmedetomidine off the table. In a younger animal, a lot of times, especially if they’re already stressed, I might… Or sometimes, I might combine midazolam or benzodiazepine. But in a younger animal that is already stressed, fearful, aggressive, et cetera, I’m probably not going to utilize midazolam because our benzodiazepines can kind of give them that excitatory reaction. And it’s even more pronounced in younger patients. That’s why for a lot of the anesthesiologists that I work with, if an animal is under three years old, we’re usually not hitting them with a benzodiazepine because it’s going to ramp up that excitatory phase.
Dr. Andy Roark:
Got it.
Tasha McNerney:
Especially if you have a stressed cat, nothing’s going to take them through the roof like a benzodiazepine. So, I’m taking that off the table too. So, what I’m left with is a huge [crosstalk 00:09:08]-
Dr. Andy Roark:
Got it. You’re taking away all of my favorite things.
Tasha McNerney:
I’m sorry. Listen, don’t worry. We have other options.
Dr. Andy Roark:
I’m like, “Oh, I’m running out of…” Yeah, my medicine cabinet’s looking kind of thin at this point, Tasha. Where we going?
Tasha McNerney:
So, we have other options and the opioid is going to be kind of your heavy hitter. And if you want to, whatever opioid you decide to use, I would just go a little higher on your dosing. And then, if you have alphaxalone in your practice, this is where alphaxalone can really shine because alphaxalone can be utilized IV or IM. We will usually combine the alphaxalone together with an opioid and then give that IM. So if this is a spicy kitty who we want to be very cardiac friendly to, we usually combine opioid plus alphaxalone IM, let them sit in a nice, calm, quiet environment. And that means don’t put them next to a dog that’s recovering from surgery and potentially-
Dr. Andy Roark:
Right.
Tasha McNerney:
Howling. Don’t put them next to other cats that could stress them out. If you can, put them as isolated and as quiet an environment as possible while they kind of calm down, let those drugs start simmering and working. Now, once those drugs have taken effect or while the drugs are taking effect, I should say, that’s the time that your staff should be gathering the supplies that are needed to unblock this cat.
Dr. Andy Roark:
Right.
Tasha McNerney:
Now, whether or not you guys like a red rubber, or you like a Foley, or you like a Tomcat, personal preference, just have a list of things together so that your staff can work quickly. I always advise that I’m a big fan of checklist. I love an anesthesia checklist, I love a surgical checklist. So if you have a little page in your nursing binder that would just say, “Hey, for urethral obstruction, this is what I want you guys to get out and ready.”
Tasha McNerney:
So that way, while that cat is simmering on its drugs, you know “Hey, I’m going to go pull the fluids. I’m going to go pull out the supplies I need for a sacrococcygeal block. I’m going to go pull out everything the doctor might need to facilitate this unblocking, make it go as smooth as possible.” So, use that time while the cat is simmering on its drugs and its analgesics to gather everything. So that way, you’re not running around and kind of… With a spicy cat and a painful cat, it’s always kind of a race against time with them, right? How much can I get done before their stress catecholamines override the drugs I’ve given them? And then now, I have to add in more.
Dr. Andy Roark:
Hey guys, we’re going to jump in with a couple of quick announcements. First off, if you have not head over to drandyroark.com recently and signed up for the Dr. Andy Roark newsletter, you’re missing out. What’s on the podcast is in our new newsletters. I like to write letters in our newsletters. We’ve got some great article stuff that comes out there. It is all really good stuff, and it’s totally free, right in your inbox. So, drandyroark.com. Sign up for the newsletter. Also, on May 21st, we have a fan-freaking-tastic workshop over at Uncharted Veterinary Conference. It is a virtual workshop. It is called, Retain Your Team : Speak The Languages of Appreciation in Your Workplace, with the one and only, Dr. Tracy Sands. Guys, this is at 2:00 PM Eastern time, 11:00 AM Pacific. It’s a two hour work shop on May 21st. It is free to Uncharted members. It is $99 to the public.
Dr. Andy Roark:
If you are trying to get your staff to stick around, if you’re trying to get your staff to be engaged, if you’re trying to get your staff to feel like their work matters, and you keep buying donuts, but it’s just not having the same effect that it used to, it’s time to do something different. It’s time to learn about the languages of appreciation. We have a self-assessment, so you can look and see how you’re doing and how you can make changes going forward. Guys, that’s how we roll. May 21st, 2:00 PM Eastern, 11:00 AM Pacific time. Head over to unchartedvet.com and click on Upcoming Events and you’ll get all taken care of, okay? Now, let’s get back into this. Talk to me a little bit about alphaxalone IM. That’s not a route that I’ve used a whole lot. So, give me just a general idea of what are common side effects? What amount of time are we talking about? Just help me feel out what to expect when I go this route with say, a methadone or a hydromorphone mixed with some alphaxalone.
Tasha McNerney:
Sure. So alphaxalone is a pretty great drug, and then we know that we use it as an induction agent. Anesthesia people like to call it propofol 2.0, because it gives you the same effects of propofol. And when I say same effects, we are… It’s great induction agent. Alphaxalone in itself is a neuro steroid molecule, works in the GABA pathways, and it is going to function similarly to propofol. And when I say that, you also are going to get hypotension the way you would with propofol if you give it in a big bolus. You also can see apnea the way you do with propofol if you give it in a big bolus. But if we’re talking about via the IM route, I like to think of it just kind of as the cream in that Oreo cookie, bringing the opioid, smoothing everything out together. Yes, I do use a lot of food references in a lot of my lectures. So, [crosstalk 00:14:03]-
Dr. Andy Roark:
No, I love it.
Tasha McNerney:
And your alphaxalone with the opioid together kind of makes this nice combination for the patient, because if we just kept relying on all opioid, we know that opioids by themselves are not usually sedating. And the amount of volume or migs per kig we’d have to give to really sedate a cat that’s already painful and spicy is a lot of opioid. And then, we could be seeing opioid side effects, right? Bradycardia, et cetera, which we don’t want. So if we combine our opioid with an alphaxalone IM, alphaxalone’s water soluble. So a much better option than something like diazepam, which hopefully people are not giving diazepam IM anymore. But you can combine these two things in the same syringe, opioid plus alphaxalone, and give that. Usually for cats, we are doing one mig per kig, right?
Tasha McNerney:
Sometimes two, but usually, one mig per kig of alphaxalone IM together with your opioid of choice. And you give them about 10 to 15 minutes. And I’m not saying that they are all the way out in the same way that they would be maybe with a dexmedetomidine or ketamine combination. But again, we’re trying to avoid those cardioactive drugs in this patient. So, they might be out enough that you can facilitate smooth IV catheter placement. And then, once you have a IV catheter placed, you can top off with more alphaxalone, give them flow by oxygen, put all your monitors on, and then release the sacrococcygeal block and get ready to go.
Dr. Andy Roark:
Yeah, cool. Talk to me a little bit about the sacrococcygeal block. Just give me some best practices tips. How do I want to set myself up for success with this?
Tasha McNerney:
Oh man, this is one of my favorite blocks to talk about. I like to talk about a lot of blocks, but if anything, the reason I really love sacrococcygeal blocks is that it doesn’t have to… You don’t have to work in a specialty practice or university. This is something that every general practice, you already have the supplies on your shelf to do this block. And it is going to be a game changer when it comes to urethra obstruction cats. So the nice thing about the sacrococcygeal block is it is just 25 gauge, 5/8 inch needle, a 1cc syringe. You want to keep this clean as possible. So if you can utilize sterile gloves, that is great. And just stuff to scrub up the area. And it’s kind of, again, dealer’s choice with the drugs. Some people like to use lidocaine. Some people like to use bupivacaine. I personally, in this patient in particular, will utilize lidocaine. Little more cost effective. And for this particular patient, lidocaine is going to last for a couple of hours.
Tasha McNerney:
I could utilize bupivacaine and desensitize that area for the six hours that bupivacaine could. But for most of these patients, once we relieve the obstruction, a lot of the pain will go away. And the nice thing about utilizing a lidocaine or a sacrococcygeal block is it is one of the very few drugs or route of drug administration that’s going to completely cut off those signals going to the brain, right? So we know, if you guys have ever had local anesthetic at the dentist or et cetera, if you’ve ever… Childbirth and had an epidural, you know that it cuts off those signals going to the brain. So that way, when your doctor lifts the cat over or puts the cat’s feet forward, or however their technique is, once they start trying to extrude that penis… With a sacrococcygeal block on board, it’s desensitized and the penis will often just come out of the [inaudible 00:17:35]. There’s no fiddling with it. There’s no kind of pulling on it, which causes a lot of irritation and inflammation.
Dr. Andy Roark:
Right.
Tasha McNerney:
So we see a huge reduction in irritation and inflammation, a much faster speed of unblocking, and overall less anesthetic time for the patient. So for us, a sacrococcygeal block is very cost effective and very effective when it comes to pain management.
Dr. Andy Roark:
All right, that makes total sense. All right, good. I feel like I’m really set up well for success here. What pitfalls do I need to look out for? Are there things that you see people get wrong? Are there mistakes that people make any? Any common trips or traps that I should look out for?
Tasha McNerney:
So for block cats, sure. Right? I think everybody’s terrified of tearing the urethra or something worse which certainly can happen. So, I would say that if you are going to do anything… I’ve seen a couple not great things happen. And usually, it’s when people are over aggressive or utilizing… The one I have seen is utilizing a stylet, kind of a metal stylet to go inside the red rubber-
Dr. Andy Roark:
Oh, yeah.
Tasha McNerney:
To give it a little more oomph. But the problem is you give it too much oomph and it goes in and I have seen urethral-
Dr. Andy Roark:
Ew.
Tasha McNerney:
Tear that way. So, just be careful if you’re utilizing anything like that. And these cases can be really frustrating. If you feel like you are trying and you’re not getting anywhere, and the patient’s tissue is just getting more inflamed, take a step back, ask a colleague if they want to step in. I think that has been really the biggest thing for me as a technician. Since I’m usually monitoring the anesthesia and I’m watching the clinicians do this, if they’re getting more frustrated, they’re going to put more pressure on that tissue. It’s not a great experience for anybody. So if you have a colleague, you just say, “Hey, I’m not having any luck with this. Do you think there is a technique?” Because again, everybody goes to vet school in different places and learns from different people. So, I have one doctor who really likes the Tomcat catheters. I have one doctor who really likes the olive tip catheters. So, there might be a technique that you haven’t learned or you haven’t thought of. So instead of keep messing with that tissue, phone a friend. Ask somebody to help.
Dr. Andy Roark:
Yeah. A lot of us not even… When you went to vet school, a lot of it was just, what kind of day are you having?
Tasha McNerney:
Oh, yeah.
Dr. Andy Roark:
That’s the classes. Some days, it’s like, “I just don’t have it some days,” and some days I can throw it across the room and hit exactly where it needs to go. But yeah, I don’t even think it’s often your training or your style. Just some days, it’s just not your day. And it’s better just accept it and phone a friend before you end up in a hole. Awesome. Any final pearls? Anything like that? Yeah, any last words of advice?
Tasha McNerney:
No. I love these cases and I think a lot of clinicians really love these cases as well, because you can see an immediate-
Dr. Andy Roark:
Oh, yeah.
Tasha McNerney:
You can see such a difference in 24 hours-
Dr. Andy Roark:
Super.
Tasha McNerney:
With these patients.
Dr. Andy Roark:
Super rewarding, yeah.
Tasha McNerney:
But for technicians, what I tell technicians is, “Use the time that the animal is simmering on its drugs to really get everything together. And don’t forget about your calcium, [glutamine 00:20:48] and your insulin. Just always have that ready and available, so when you run that blood work, if you happen to see a potassium of, I don’t know, 10, you’re ready to go with some intervention.”
Dr. Andy Roark:
Good, that’s so awesome. We talked at the very beginning about Anesthesia Nerds. Tasha, do you have favorite anesthesia resources online, outside of Anesthesia Nerds?
Tasha McNerney:
Oh, yeah. So I think that, pun intended, the Think Anesthesia website is actually a really great website and it offers a lot of free resources. So if you’re thinking about getting some CE and you don’t have it in your CE budget to actually go to a conference or even sign up for a webinar that may cost money, Think Anesthesia, which was brought about by some of the anesthesiologists at [Durox 00:21:32], is a really fantastic website. They have webinars and articles on anesthesia recovery, anesthesia induction, anesthesia for rabbits, all kinds of stuff. So, that’s a really nice resource that I like.
Dr. Andy Roark:
That’s awesome. I’ll put a link to that in the show notes. Thank you so much for being here. I always appreciate your time.
Tasha McNerney:
No problem. Thanks for having me.
Dr. Andy Roark:
And that is our episode guys. I hope you enjoyed it. I hope you got something out of it. If you are on the Facebook, consider checking out the Veterinary Anesthesia Nerd group. Those guys are so great. It is awesome to see people who are passionate about a thing, sharing their passion. And that is that group. Gang, take care of yourselves, be well. I’ll talk to you soon.
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www.baysbrass.com
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