So welcome. My name is Doctor Kirsten Rongren and I am the consulting veterinarian at Many Pets Pet Insurance, and we are very thrilled to have you guys joining us tonight. I am really stoked.

I'm really excited. I am a dental nerd, and I have been for a very long time, so this has been something that has been on my wish list to do CPD for you guys, . For much more than a hot minute, so we have a very wonderful panel of guests tonight that are going to be going through lots of tricks regarding mastering anaesthesia and veterinary dentistry, and we've got the full gambit.

We've got the nursing side, we've got the dentist side, we've got the anaesthetist side, so, very much going to be a good session in terms of Different spectrums of thought and different just approaches to things and kind of every person on the team can be thinking about that. So a few housekeeping things. I just want to go through if you have questions, please put those in the Q and A box.

So we are going to have some time a little bit later where we will be answering your questions, and when I say we I mean these lovely ladies who are much smarter than I am are gonna be answering your questions. So if you do have ones that you want to be answered, please. Put those in the Q and A box.

The chat is more for just things like comments, a little bit of other like logistics things and Dawn from the webinar vet can put information in there if you guys have more logistics type things. So I'm just gonna do a quick little intro for all of our speakers tonight and then I'm going to pass it over and we're gonna start with actually a video. So, quickly we'll do the little intro.

So we have, like I said, 3 great panellists tonight. And I want to start by thanking them for joining us and also for thanking Mars for doing this in partnership with us. So this webinar is sponsored by us at Many Petts and also our friends at Mars who have worked really hard to help put this together.

So thank you to them for being our, our buddies in this endeavour. So let's start with Rachel Perry. So Rachel is our dentist who is on the squad tonight and she has been in dentistry and oral surgery for 25 years.

She became an. EVDC and an EBVS diplomat in 2016 and an RCVS specialist in veterinary dentist dentistry in 2017. So she definitely has seen her fair share of cases and I'm very much excited to pick her brain.

She also has a postgrad certificate in veterinary education, and is a fellow for the Higher Education Academy. She's also the director of Perry referrals, so she is rocking it, running her own business. Her and Stacey kick and booty.

And so I'm very much excited to get their opinion on these cases. So she has also done a lot of lecturing internationally, published research, published in textbooks. She also reviews for feline medicine and surgery.

There's a lot of things going on, so we're very, very thrilled to have Rachel joining us. But the thing that I like to talk about is what do these people like to do outside of veterinary medicine. So Rachel likes to talk about dentistry all the time because she also likes to teach and Improve standards of dentistry through education of veterinary students, vets, and nurses, and she's also just casually the president of the European Veterinary Dental College.

So just a few things on her resume and we're very happy to have her here. Next, I'm gonna move on to Stacey. So Stacey is our qualified RBN who qualified in 2014.

She also has her nursing certificate in anaesthesia and dentistry, and then most recently her advanced certificate in anaesthesia. So She is the first and currently the only RVN in the UK to hold the accreditation of lead vet nurse practitioner in anaesthesia, which is really cool. So lots of good knowledge there from Stacey.

She has done her BVNA oral care nurse certificate, her BSAVA merit and anaesthesia and emergency and critical care, and her ISFM certificate. We've got a lot of cat people in here, which I truly appreciate because I was a feline only practitioner in the states for many years. So you've got lots of cat people on board.

Stacey also works with Rachel, and she is also a RCVS and, oh, sorry, now I'm getting excited. So, and she has been working at Perry Referrals with Rachel since October of 2023 and runs her own CBD company as well, so Bertie's Boutique. So Stacy does CPD that offers relatable, affordable, stress-free CBD in the form of monthly webinars, face to face events, and so that is something that if you guys want to check it out.

That is www. Bertie's Boutique.com, and we can throw all this back at you at the end too, so you don't forget.

And then we also have a beachgoer on our hands. Stacey likes to read, spend time with her cats and rabbits, and then baking and swimming, and it is also available to look at all of our good posts on Instagram. So if you don't already follow her, that's a place to check.

So last but not least, we have Jody, we have our anaesthetist on board. So she is a Liverpool girl, graduated there in 2011, and after a little bit of time in rural mixed practise, which good for you, that's hard work, returned to Liverpool to do her internship and her residency in anaesthesia and became a European specialist in 2019. So in 2020, she made the move to the South and She is now at North Downs with these lovely gals, and she is definitely taking on challenging cases and has a lot of experience and wisdom to pass on to us.

She's also the clinician quality lead at North Downs and takes a very keen interest in safety and non-technical skills. So outside of work, we've got a house renovator on our hands, which I will try to avoid asking questions on, and Also knitting, scuba diving, and board games, which I feel like is a very diverse list of interests. So again, we've got a stacked panel.

Thank you guys for joining us and like I said, if you do have questions, those go in the Q&A box. Comments can go in the chat, but we're gonna start off with some video content first. So sit back and relax, and then I will pass it back to Stacy.

So the first thing we need to be looking at for our patients is having a really good read of that clinical history. Any notes they've had an adverse reaction to any anaesthesia before and continue that conversation with the owner as well. So let the patient know a little bit of time to get used to you.

Hopefully they walk out on their own. Good listen to their chest auscultating the heart and chest and their throat and lungs, and feeling for pulses at the same time. Try and be a little bit hands off with the cats if you can.

They're not keen on being overhandled. So we've had a good listen, everything's looking great and it's a really good idea to take a blood pressure if the patient allows it. Cats are gonna be more tolerable to a device placed on their tail.

And we know it's probably gonna be a little bit elevated, but we're just checking for anything of extreme abnormalities that may tell us not to proceed with the anaesthetic. I'm gonna be taking their temperature as well. We take it in the ear, the cats prefer that a little bit more.

I'm gonna be checking for any dehydration. We're Gonna have a feel of the abdomen, see if we can feel anything peculiar in there. Remember anaesthesia, the dentistry isn't just about the mouth.

We need to have a good look at what's going on everywhere else. And then check the eyes for any signs of dehydration, any discharge on the nose or eyes. Check that the mouth looks nice and clear, check her capillary refill time and mucous membrane colour, and we'll be talking to the owner if the owner was with us at that point and let them know.

And obviously lots of fuss as well. She's being a very good girl. Really accurate that we need to get an accurate daily weight for that patient.

Even if they weighed a few days ago, things can change quite quickly. We need to make sure we've got that weight. So next we're gonna look at placing an IV catheter and if we can do this in our patient's conscious without causing any distress, then that's ideal.

So gentle handling, quiet clippers. Quiet room. And then once we've got the IV in, that we can then have a chat with the vet or in our case, the anaesthetist in charge of our patient.

Tell them about the clinical history, or our TPR, what our vitals were, any concerns, any meds they're on, and they can then make a, specific, anaesthesia plan for our patients. And here we are calculating all of our emergency drugs for our patients, and as well as our pre-medication drugs that have been advised. We are going to make sure we have our trays separate for our premedication to make sure there is nothing mixed up.

So here we have our meatomidine, clearly labelled, and our methadone, which is our premedication of choice under the guidance of the vets, and the flush, and that's kept in the tray. And then we move on to our Atipa which we always will draw up if we're using an alpha 2 and have that in the room with us just in case we were to need it in an emergency situation. That's drawn up, labelled and ready to go.

Then we're gonna have our induction trays, so this patient's having a little bit of a co-induction of alfaxolone and diazepam. So again we've got the flush ready, clearly labelled alfaxolone. We use propofol as well.

Not obviously at the same time as alfaxolone, but either or is fine, and then we're gonna co-induction with a benzodiazepine of diazepam for this patient. Again, in a separate tray, so there's no confusion about what drug is where. And then we're gonna move on to our what we call incubation trays, so we have everything that we need here.

So we keep all of this together to make sure that it's all in the same place and everything we need. So we've got the incubies ready for incubation for our feline patients. Make sure that that is working and that there's enough in there.

Always important with every patient to get used to using a larynge scope, the lightweight ones from Ace veterinary supplies are amazing and check that the light is working. We use armour DT tubes for our patients. They have a spiral of metal going through them, so not for use for a CT or MRI.

They're more flexible, so you will have a stylet inside them. But this means that these tubes can't kink when we're manipulating the head, as you can see here. The PVC ET tubes are also good, but they will kink, so it just depends on the setup of your dental room as well.

As you can see here, these guys can occlude if we're not too careful. We need to be making sure that the pilot balloons and the cuffs are working correctly, so prior to any anaesthetic, you should be checking the cuff of your ET tubes, making sure there are no leaks and leave them inflated for sort of 15 minutes or so to make sure there's no slow leaks there. Any leaks, and they should be disposed of.

We're gonna make sure that we've got a plastic ET tube tie. We have the nice colourful ones that don't need special knots. If you want to know where to get them from, just send me an email, just a simple bow through the ET tube, and then we tie them around the back of the patient's ears.

And the plastic means that the water isn't whiking up round the back of the patient's head, making them all cold and wet. It doesn't get caught in the dental drill either, and it's just a normal bow at the back, nothing fancy. Then you can undo that nice and easily should you need to, and you can reuse these as well.

We, once we're incubated, we're gonna be checking that cough pressure on the trachea. So with cats, we're gonna go up to about 16 centimetres of water, and dogs around 20. Different literature will say different things, but that's what we do, and we're gonna make sure that we're using an accurate device such as a manometer or an AQ cufffi.

Both are fine, one is more reusable than the other. We're also gonna make sure we lubricate the eyes regularly, we don't want them to be drying out, and we use something like cellally disc it's it's a bit thicker, lasts that little bit longer so you don't have to keep going on the surgical drapes or getting around the surgeon's case as much, so this works nicely. And then we always utilise local nerve blocks, but you have to be so careful that they're not getting mixed up with all your other drugs, so we keep them in a completely separate tray and nice and labelled as well.

So you can see here we also have our suture material and our polishing paste and head and a scalpel blade, and that buppica is very clearly labelled, and that tray will be kept in the opposite side of the room from any other drugs to ensure there's no accidental IV administration of the drugs. We make sure that we have suction available, moving on to protecting the airway for every single patient. Now you may not have it on your machine like us, but you will be able to have a separate unit and it's not too expensive, for the regurgitation or bleeding, and also for the amount of water that we may be using in the mouth.

Packs are really important to utilise. So we use these ones that can get quite small for cats, 5 by 5 centimetres and bigger, up to 10 by 10 for dogs, and 7.5 is the interim size.

They have a nice tail there, so you can leave them out of the mouth of the tail and you can just remember to change those regularly. How often is changed will depend on the level of water use that you are using. We use packs for all of our patients.

It's really important to know where your crash box is and your emergency drugs and to have the, recover CPR algorithm to hand and everyone trained up and then have those drugs somewhere that you can reach. And then we're moving on to keeping our patient nice and toasty warm, so with our smaller patients, we start with a heat pad, really thick vet beds, and one of these mats to go under the patient's head. It's also nice and soft for the surgeon, and that will allow the water to just seep right through.

Make sure there's no gap between that and the beds. And then for our patients, they go on this busty beds, it's got beans in it and it just helps support the patient and insulate them from losing any of their body heat as well. And our patients will be in dorsal recumbency for this with their heads allowing a natural drainage caused by those beans as well.

All of our patients are very fashionable, they're gonna be kept warm in some sort of jackets, but make sure whatever you're using is very easy to get on and off in an emergency situation and that you have space to auscultate the heart. They're also gonna have little sockies. I'm gonna use that on all 4 ft to keep them nice and warm.

All of our patients will have a puppy pad or kernel liner with a hole placed over their face, and then the muzzle comes through there, and all the water that's used will then, or blood will then go through onto that and not on your patients. And our patient will have a bear hugger with a nice fleece blanket. We don't like towels, they're a bit too heavy, and they're really gonna be tucked right in and cocooned right in there.

They're gonna be burritoed right up, and that will insulate all that heating, stop the patient from losing heat or losing any of that heat from your bear hugger. And this is how we make the little hole for that face cover, again, I'm gonna place that through, muzzle comes through, you can reconnect your breathing system. So moving on to our machinery, we need to make sure we've got oxygen attached.

We have connected our breathing system to the fresh gas flow, that we have a nice a correct amount of inhalant, and we're checking that that is also working. And then we're gonna put the flow up a little bit on the oxygen and make sure that that is also happy and working. We're gonna connect our scavenging to make sure we're keeping everybody safe, and we're gonna check the valve is open.

We're gonna connect our capnograft to our elbow to release tension on the ET tube and airway. And then we're gonna check by occluding the ends, closing the valve, and pressing, pressing the flush button of the oxygen, that there are no leaks in our system. And just remember to always open that valve up.

We are really lucky we have a multi-parameter, so we're gonna make sure that that's all set up and working happily. And don't forget that pulse palpation, palpable reflex, looking at their colour and listening to their chest is also important and we will need to do that to coincide with our fancy monitors. A happy anaesthesia and a happy patient is one that is interested in food after dentistry.

So hopefully following some of these top tips and following on some questions that we can answer for you this evening, you'll feel more confident and your patients will have a lovely amateur. All right, so that is the end of our video content. We're just trying to keep things exciting for you guys, and I am going to throw it over to Stacey, who has got some slides she's going to go through with you, and we'll go through those first, and then we will open up the floor for some questions.

So over to you, Stacey. So thank you so much everyone for joining us and for Jodie and Rachel for joining me on the panel. I think it's really important to have a selection of people that are involved in dentistry, it doesn't take just one thing.

So I'm just gonna go through a couple of points that we weren't able to entirely squeeze on the video, and then we're gonna open up for questions. So this may answer some of the questions you have off the back of that video or maybe ones that you had, so. There you go, so a lot of people ask about whether we use cuffed ET tube in our dental patients, particularly with cats, and the answer is yes.

We do for every single patient and there's ways of doing this safely. I understand there are concerns with using cuffed AT tubes and cats, but I think there could be a concern for all procedures and treatments that we carry out. And we can definitely mitigate those, and the reason for using a cuff DT tube is to really secure that airway, make sure that you've got a good seal, and there's no reason why it needs to cause any damage if we're using our ET tubes properly.

So first of all, ET tube choice, A should be technically. In the bin, if you wanted my honest opinion, it's not something that we ever use, but we like be the PVC ET tubes. I'm not keen on those orange, or red rubber ET tubes.

You can't, check the pressure of the cuff. They have the wrong type of pressure cuffs, so you're more likely to get a tracheal tear with these guys. They also get quite firm after a while.

You can't see if they're splitting inside. You can't see if there's any any regurgitation, you can't see the patient breathing through them, and you can't see if they've definitely been cleaned, and I just think there's a little bit more irritation with those, so. ET tubes, the new ones are not expensive.

They're very, very cheap and you can still reuse them, and you can intubate very easily with them as well. So I would recommend if you take anything away from this, is to upgrade your ET tubes. Ace Veterinary Suppliers sell the PVC ET tubes, and they are very reasonably priced.

The reason we like those PVC ones is that they have a high volume low pressure cuff, whereas those red, rubber, orange ones have a low volume but high pressure. So we also have a Murphy's eye, which you can see along the top, so if that bevel tip was to be occluded for any reason, then this patient can still get some oxygen and God forbid they were to chomp down or inhale part of their ET tube. It has a radio opaque line, so an X-ray will tell you where it is and none of these things are on your red rubber ET tubes.

So the top ones we can see are like the orange red, rubber ones, so low volume but high pressure. So there's a really sort of peaked pressure point there that can cause damage to the capillary beds of the trachea. And then you've got your, nice happier PVCET tubes there that have a higher volume of air in that cuff, but it's over a larger surface area, so the pressure is much lower, so you're less likely to cause damage.

So these are not good. We mentioned briefly about using the armour DT tubes, that's a personal choice, but remember if you do want to start using them, you can't cut them down. Don't use them if patients going through the CT or MRI because they have a metal down the middle and get a stt because that'll make it much easier for you to transition if you wish to use these.

Definitely use a laryngoscope, visualise the airway, and don't be shy. Use an assistant. I keep seeing videos on social media about people having mad skills incubating cats upside down on their own.

There's no need for this, and we shouldn't be doing it. This is also a time to be visualising the larynx, the back of the throat, and see if anything's untoward and what's going on. And having an assistant, don't be shy to ask them to elongate that neck or head more, and it's good to communicate at this time as to what's needed.

Avoid spasm with cats when you're using any type of ET tube, so make sure they're appropriately anaesthetized and using the local anaesthetic sprays such as incubies and allowing it to have time to work. And having a range of ET tubes and checking that the cuffs are working before you place them, and they're not sort of inflating on one side only, which could cause damage, but if you've checked them pre-op, then you should be OK. And if you've got different sizes, you're less likely to have someone repeatedly just try and get any ET tube in because that's the one you have.

If you have a look with the laryngoscope and think you need something smaller or bigger, then you've got them right there. And then making sure that they don't move within the patient's, throat and they're clear rather, then you can do that by securing the ET tube, as soon as it is placed. And as I said, we'll use the plastic ET tubes and I can let you know, where you can get those from.

So always use an appropriately sized cuffed ET tube for dentistry, visualise well your incubation, intubate very carefully, and some people would like to use sterile lube, but make sure it's not the one that's been open for ages and used on bottom thermometers. And most importantly is to measure the pressure of the cuffs so we don't overinflate them. Just listening and just feeling and thinking, oh, that feels right, is, is not going to be good.

So you can safely inflate the pilot balloon, as I showed you on the video with a manometer or a sort of more handheld, device, such as the Aal cuff fill there on the left. The one on the left works for 100 times but it's cheaper, but then you have to replace it. The one on the right is more expensive, but as long as you don't break it, will last a very, very long time.

So there's some studies out there that I've narrowed down for you because I think this is such a hot topic, that we shouldn't be exceeding the profusion pressure of the capillary beds of the trachea. I've converted that into centimetres of water as that's what your manometers and aid your cuffy work in. And that's 33 to 47 centimetres of water, but we don't need to go up to that limit.

So I read two studies and one showed that 24 to 32 centimetres of water was enough to create a seal and another said that 20 was. My opinion on what I do on a daily basis, obviously this is my opinion, is that we don't tend to exceed 20 centimetres of water, but I use slightly less for cats, so I will use 16. And you can see there that there's, an article that you can read for yourself if you'd like more information.

One of the biggest causes, I think, of tracheal tears is not disconnecting your patient prior to turning, and this should be whether you're turning them a little bit to the left or right, or turning them around completely or moving them. So this video will show that we're going to turn off the inhalant, and then we are going to empty our reservoir bag and then disconnect our patient with the twist being on the hand that's on the breathing circuit, not on the trachea. I'm gonna talk to my assistant there and we are discussing and then counting down the turn for our patients supporting that head.

Reconnecting our patient and getting that inhalant back on. If you turn your patient with the ET tube connected to your breathing circuit, then you are just asking for the trachea to have the ET tube twisted within it, and that's gonna twist along with that tissue of the trachea, and that obviously is not going to be good. Other things not to do, moving away from ET tubes is do not use a spring loaded gag.

There is no need. It will cause damage. I think just not a nice idea to have your mouth forced open for that long sometimes with your dogs, you can use a one mil syringe barrel cut down as power on the right.

And we do know that in cats, excuse me, it can cause excessive opening and tension on the maxillary artery, which can cause, post-op blindness in cats. With cats you can just use a needle cap cut down to give you enough visualisation, and some people use old fluid drip lining or if your ET tube cuff doesn't work, then instead of bending the whole tube, you can just cut them down and use them as little safe mouth gags. All of our patients are dressed as soon as possible.

I don't want them stressed, so if a dog is a bit cold when they come in in the winter, and particularly they'll have a little coat on. All of these packs are available at Bertie's Boutique.com.

If you're watching abroad, then email. We do ship abroad, but we'll just let you know how much it is. And we've just got nice new fluffy lined, fleece-lined, button up, very durable ones, for cats, which work really well.

It's not very often that I have to reach for my, forced warm air blanket, because we're just keeping them warm and stopping them losing any heat in the first place. It's also better for the environment, not to have to keep plugging stuff into the mains. These guys can be worn in CT and MRI.

A lot of our dentistry patients may need other services, particularly CT with head trauma. And something I didn't talk about about keeping our patients warm is that you can get the little incubators for our patients, so really hands off warming for pre and post-op when needed. And that was my little birthie cat there, he was recovering.

He was a bit cold when he had, some other surgery done, at the time. And so he woke up and you can offer oxygen and you can monitor these patients whilst they're being warm and given oxygen postoperatively. A lot of people hate anaesthesia dentistry because you don't get access to the face.

And we're taught about so many things that we want to monitor with the face. You can still get to the face with a good communication with your surgeon, but you can learn other ways of placing and monitoring, for example, the pulse ox. We could still be using it.

Yes, it can be naughty and give you some weird silly readings, but we should still be using it. And you can place it maybe on the groyne area, on your little toe, or on the penis, or on the vulva. And finally, this isn't a managing hypertension session.

We could talk about this, Jodie and I particularly for days, at least a whole day or a few hours. But if you'd like to, think about managing hypertension, everyone wants a magic answer. There isn't one.

Definitely be monitoring your blood pressure for all of your patients. Every single patient, dog, cat, there's a red panda up there that we saw, he had his blood pressure taken to. Rabbits, kittens, old dogs, brachy panics, not just the old sick ones.

Every patient should be having their blood pressure monitored. And in order to treat the hypertensive episode, we really need to understand how blood pressure works and to safely treat it, we need to first understand what is causing it. And if you're interested, Bertie's Boutique in June has a managing hypertension webinar, so feel free to have a look and hopefully we can discuss a little few tips as well if you'd like this evening.

So that's everything I have to share on my bit this evening. I'll be here for questions as well, so I'll stop screen sharing, then maybe we can answer the open the floor to some questions. Lovely, thank you, Stacy.

I feel like I, I love always picking up tidbits even when you've been doing this for 10 years. I literally am just coming up with my 10 year vet school graduation anniversary, and I'm like, I'm supposed to be the adult in the room, but I still love for people to tell me new things or refresh my brain on things that I haven't seen in a while. So thank you for that.

So we do have a few questions coming in, and I know feel free. We have now reached the point where we want to treat this as not only us telling you things, but we also want to know what you want to know. So if you have particular questions about anaesthesia and dentistry, tips, tricks, probing the brains of these very smart individuals, this is your opportunity to do so.

So I'm just gonna jump over to the Q&A like I said, that would be the best place to put your questions. I think there's a couple in the chat, but we can come back to those, . The one that I'm seeing right now is people were asking about the tube ties, Stacey, so I know I love those kind of elastic plastic tube ties because I think they work really well too.

So just quickly before we jump into more technical questions, what is the best place to get those? But they're actually just Scooby-Doos. So wherever you buy them from, we do have a little trial pack on Bertie's Boutique if you need to buy them from somewhere a bit more veterinary, if that's what your clinic requires.

We sell them a little cute envelope that you can put the teeth in to give to the owners for the dog or cat tooth fairy. But you You can just buy your own, a whole pack of Scooby-Doos. We can reuse them, you can cut them in size.

What's really good is that they're really bright colours, so you don't lose them within the fur, and the water doesn't whiick up through the back of the head. The drill doesn't get stuck and make that horrible noise and maybe get an issue with your drill bit. So yeah, I, I really appreciate using them and.

They're plastic, but as I said, you can reuse them several times. The only difference with them is if you're used to using something like a bandage material and you're using that to hold the skull, the sort of the maxilla open, for incubation, they, they won't take the weight of a big skull. I use my hands for holding a head up for incubation, so it doesn't bother me, but if it's something you're used to, maybe you'll need to use a bit of wild bandage or something to open.

The jewel for incubation and then tie it in with something plastic for the the benefits that we discussed, but yeah, they're, they work a dream. I, I agree 100%. So, OK, so let's hop over to the Q&A.

So the first question we kind of already talked about you, you hit it very early on, which is about routinely using cuffed ET tubes and cats, so I won't spend too much time on that one. So next one coming up I'm seeing is definitely some comments on the impressive pre-op wrapping of your patient. For, you know, preventing the temperature change that we don't want to start to see that creep downwards, so we're just trying to trying to hit it right out the gate.

So the question kind of is, do you use a thermometer readout to prevent overheating, plus or minus linked to the heat mat, ie to switch it on and off. So I think essentially that's probably a multiple step question, but who would like to, who would like to take the the comments on how we're kind of managing that hypothermia before it becomes a problem. Yeah, I can, I can leave with that in, we don't use heat pads in our larger patients, so I only use my heat pad in a patient under 5 kg, because you can get thermal burns with your patients, particularly if they're placed very directly on the heat mat.

For the electric heat mats, but as you said, you see a thick bed bed and then you'll see a beanie bed, and then the patient's wearing a jacket. So there's 3 layers between them. But they still, with 3 layers, wouldn't place a heavy patient on them.

Our smaller patients are more inclined to get small, colder, sorry, because they're so small. I wanted to continuously their temperature. I don't want to cook them.

So if at the minute you're not doing a lot for temperature control, if you were to put everything into play that I just suggested, you will maybe have a very hot patient. So, you know, put one element in at a time. So yeah, I am routinely monitoring their temperature.

I don't actually turn the forced warm air blanket on unless I start seeing a temperature drop. And a lot of the times because I stop them from losing the heat, I trap that heat in. I don't need to use it anyway, but I only use it once I see the patient drop.

And then when they get up to about 38 degrees, I will turn active warming off. So you already unplug the heat pad, I turn off the forced well on my end, leave the passive things on. And you can always remove a blanket or add a blanket.

So, kind of see what the patient needs. But I know that Jodie works in other areas of the hospital as well and has other ways of keeping patients warm that's probably important to discuss as well if you wanted to. Yeah, so I mean, I think we use heat mats more in other areas of the hospital where we can't cover the patient so well, because dentistry is great for being able to swaddle the patient, but not so good for things like abdominal surgery.

We use the hotdog, heat mat warming system as that seems to be the safest one available on the market, and it's certainly the one with the most research. Available, but we do use it very carefully. We don't use it for more than an hour, and we don't use it in theatre, we use the, the 4 star warming theatre because that's lower risk for bans.

Definitely, and I think that's, I think one thing is that if you've ever see a patient get a burn from any sort of warming device that will scar you for the rest of your career and so I think it's just being very conscious about choosing what's obviously right for the scenario that you're in. Dentistry is nice because we can. Completely cover them we have that luxury which we're not always so lucky.

So kind of while we're on the topic of temperature, I also saw a question that I actually get asked a lot as well, even in general practise is how accurate is the ear thermometer. So I don't know who wants to tackle that question, but I think it's important to talk about while we're talking about temperature. I mean, I can answer that one.

It's, it's gonna depend a little bit on the brand, that you're buying, and mainly it's how you use the ear thermometer. It's usually gonna read a little bit lower than your rectal thermometer or your esophageal pro, but it's great for trend monitoring. And it's great for not stressing patients out before surgery, so it's gonna give you an idea, and I'd expect your actual temperature to be a little bit higher, but you do need to point it at the tympanic membrane and not just on the pinna.

Definitely. Excellent. So I'm going to keep scooting us along and I'm kind of gonna jump around a little bit, but one of them that is coming up, is do you deflate the tube before turning, and it says Rachel Perry is going to answer this question live.

I must have pressed on the button by mistake. We don't normally deflate it. We don't deflate it until, till the end, but, I'm happy to be corrected if I'm wrong.

No, you're right, we don't. Do you, Judy? No, we, we don't deflate before turning as long as you've disconnected everything, the tube should turn with the patient.

It's just really important to support the head well so the tube and the pilot balloon are not getting caught on the table during the time. I would worry if you uncuffed it, turned them, that's when they might regurge, you've then got an unprotected airway. Yeah.

Definitely. Excellent. Rachel, you just got lucky.

I think I was trying to take the answer and then I instead clicked on answer live. That's OK. I mean, it's, it's a good thing to to just remember, OK, why are we, which parts of the system are we disconnecting?

Which parts of the system are we moving versus not moving, and why are we doing that, right? Especially I think because I, I get asked that question a lot in a teaching scenario. I have veterinary nurse students and and vets.

Saying, you know, why are we keeping the cuff inflated and especially for dentals, if you're not packing off the, the mouth well, you worry about aspiration of all the gunk and water we're squirting in there. So it's important to remember which parts of that we are moving and not moving. So I have another question on here about local blocks.

So what are your thoughts on lidocaine versus bupivvicaine or a mixture for dental nerve blocks? I think this is a really good question. We've had vets express concern if multiple blocks are used, that the patient could then bite their tongue on recovery.

I feel like that's a very loaded question. Well, I'll give you my opinion on it, and then, perhaps Joli can, can give her opinion. Lidocaine obviously is going to be quicker to have an onset of action, but then a shorter duration of action.

I prefer bupyvicaine so that I know we're going to get some postoperative analgesia, as well. So that's my preferred choice. It's not wrong to use lidocaine.

You just need to know what to expect with either drug that you're using. I wouldn't recommend mixing two drugs because you don't know what effect you're going to get. It sounds great if you mix something that works really quickly with something that lasts a long time, you're gonna get both effects.

But in reality, you don't get that. You're mixing two, weak bases, you're gonna alter the PKA values, and you're actually diluting both of your drugs, so you don't know what effect you're going to get. So pick one.

Or the other, and then, and then stick with that. In terms of avoiding, tongue trauma postoperatively, my two top tips, for that are accurate block placement. So you need to be really careful that you're placing your needle adjacent to the mandibular foramen, to do the inferior alveolar nerve block, and not anywhere near the lingual nerve, which is slightly more medial and caudal.

And the other thing is to use a much perhaps smaller volume. If you're using a big volume of local anaesthetic, it is gonna disperse, and you may potentially, desensitise the lingual nerve as well, and therefore desensitise the tongue. So, my top tip for that is to use a smaller volume, of drug and make sure you're very accurate with your needle placement.

So, Jody, maybe you can add some comments to that as well. Yeah, certainly, it's, it's quite a, a big question really. In terms of lidocaine versus bpicaine, I agree with Rachel.

I'd rather have that postoperative analgesia, so you have the longer acting local anaesthetic. For mixing lidocaine and bivvicaine, there's several different studies with several different outcomes as to whether or not you do get a benefit. So the theory being quicker onset and still a long duration.

There's some studies to show that you don't get that quicker onset and you then don't have such a long duration. So I tend not to mix them, except in circumstances where I need that block to be effective relatively quickly. So the only time that I go a bit dirty and mix them is for, boas surgery where we want the surgery to be relatively quick.

So I do my maxillary nerve blocks with a mixture of the two, and that's more so that I can avoid having to give high dose opioids, in those patients. But for everything else, I tend to pick the, the drug of choice for the situation. And I think with dentals, you're gonna be doing your X-rays, you're gonna be doing a bit of cleaning to see what's actually going on beforehand.

So you can usually get your blocks in far in advance. We say 20 minutes on that would be voting, but realistically, if you do an epidural, you see that rectum dilate pretty quickly. So I was actually just going to ask, not about the dilation thing, but about how long do you wait, because I think that a lot of people think, well, I, they feel like they want to shy away from buppivoine because of the time it takes to, to kick in, but I think that that's a common thing that we would say.

I don't know that it necessarily takes that long. Yeah, clinically you see some effect within I, I'd say 4 or 5 minutes, so really, really quite quick. And if you get a no susceptive response before that, you can give a little bit of extra analgesia to cover you for that period, which is fine.

And as for the lingual trauma, I think, there's a few reviews in, in people recently that they recommend still doing the bilateral blocks, and I think that is better for welfare because it's such a rare complication. And it's only been reported in, in very isolated case reports in the veterinary literature, and their reports where they've used relatively large volumes of the local anaesthetic. They're usually using about 1.5 mils to 2 mL per site, which is significantly more than Rachel is using.

I think as well we need to have a think about when we make our block choices. Obviously, it's not my decision as a nurse, I don't prescribe, but you need to think about your recovery and the sort of team and setup that you have, because if you use lidocaine, you're definitely gonna need to be administering some more analgesia postoperatively because it's gonna have worn off. Do you need to make sure the team are there and understand, are trained to painscore, because you're gonna need to be doing that quite frequently.

If you don't have anyone doing that, you know, ideally we should be, then the pivotca would be a better choice because it should, technically, we should still be pain scoring them, but technically it should last longer. So you don't have so much patient intervention, like, you don't have to keep prodding them quite as often. So there's also something to have a think about.

And, you know, whether you have a capacity for that more intense nursing care afterwards, you can't just do a block, take the tooth out, and it's lidocaine, and then expect them to be comfortable 2 hours later. Probably gonna be a bit more uncomfortable in comparison to the cat in the next kennel that might have had bpica. So it's also thinking about what you have as a setup and how good you are and comfortable and trained in performing pain scoring as well.

Definitely. I think one of the things that I've noticed, I don't know if you noticed this as well, is that when you get into practise and you're doing these dentals, a lot of times, we think so much about the pain relief during that there tends to kind of be, once they seem comfortable and they're resting and they're recovering in their cage, we need to remember that there's still a lot of time that we need to cover in terms of pain relief, and that's especially true for You know, a lot of these new grads and, and students that are coming out and kind of yeah I finished my dental, but I'm like we have to remember that there's a, we just did some major extractions and so there's some pain that needs to be covered, so wonderful. So while we're kind of talking about local blocks, I did see a little side question pop up in the chat and it was asking about doses for lidocaine for nerve blocks, so I might politely request your recommended dosages for lidocaine and for buppivicaine while we're while we're on the topic.

Well, I use biviccaine, the reported sort of toxic dose, if you will, for buppicaine is, is 2 mes per cake, but there was, a case report, I think, in a cat that became bradycardia. I think at about 1 MB perk total volume. So I'm quite cautious, particularly with cats with my with my dosing, and we'll always calculate a maximum or toxic dose for that patient.

And that's really important in cats and small dogs to make sure that you're not giving them a a kind of total volume that's over the, the maximum dose it can tolerate. But realistically, most patients, I'll be putting in maybe 0.1 of a mil, maybe 0.2, 25, something like that.

Not, you know, usually not much more than that, unless I was doing perhaps some maxillary block in a, in a dog. But, certainly for the inferior alveolar, block or any kind of in orbital block, then I'm not using bigger volumes than that. And You know, how do we know if our blocks are working well usually by what we're then doing with our, you know, inhalants, can we get that reduced and is the patient on a nice stable plane?

I don't know, Jodie, would you like to comment on the volumes that you're using for different sort of, oral surgeries? Yeah, so we, with local blocks, the most important thing is the volume so that you have sufficient volume to cover the nerve, but not too much volume for it to spread where you don't want it to go. And once you've worked out the volume you want, you then check that you're not gonna go above your toxic dose.

So as Rachel said, you want to be avoiding going above to make the cake with the b the can, and you can dilute it if you need to. And with lidocaine, without adrenaline, you don't want to go above 5 meg per pig and dogs and, and probably 3 to 4 perig and cats. But the toxic doses are the dose that is toxic if that dose is injected IV.

Be a bit more cautious with your dental blocks because it's a very vascular area. If you're doing, fascial plane blocks, etc. It's less vascular and you've got lower risk of absorption.

But I tend to, I go a little bit higher with my volumes and Rachel, but not massively higher. So I'm probably up to 0.5 mL in a big dog, for most of the, the vision I blocks and kind of 0.2.3 miles for cats.

Thank you. That's super useful and very practical, I think for people doing this out in the clinic. So again, I'm gonna kind of keep the topic on drugs if you guys are OK with that.

And we have a question here about, do you ever use midazolam intra-op to manage lightness and depth during dentals, if not, no susception due to pain. I mean, I can take that and Stacey can also give her opinion of midazolam, because I know Stacey has some feelings about midazolam. Very, very rarely.

So I think if you're struggling with anaesthetic depth and you're doing a painful procedure, how do you know that it's not noise deception related? So I would tend to deepen my plane of anaesthesia with something that is also an analgesic. And depending on the case, and the status of the patient, if it's a very healthy patient, maybe I'll just give it a little bit of metaomidine, so like 1 mcg per kilogramme.

Tiny homoeopathic doses, maybe 2 mcg per kilogramme because that's gonna give you a max bearing, deepen your kind of anaesthesia, but also give you some analgesia. If it's gonna be a longer procedure and it's having something quite significant done, so multiple extractions of other gingivitis, then we might start a ketamine CRI at that point. Again, it's giving you both the max bearing and the analgesia.

I would only really be using midazolam or diazepam to deepen the plane of anaesthesia in the higher ASA patients where I'm worried about using my alpha 2 agonistsulcotamine, so. In those cases I might think about it if they're just a a very annoying dog that won't stop panting, and it's been like that before we did anything painful then it's a useful thing to try, but I'm probably more inclined to go with the opioid at that point. Stacy, do you, are you, are you, are you so bursting the scenes to talk about midazolam?

I don't know, I think. I know, I completely agree on, on, on Jodie's, thought process. I've never thought, or I'd quite like to add some midazolam because they're a bit light under anaesthesia.

And I, it's not something I've ever been asked to do by the anaesthetists either. As Jodie said, we tend to use midazolam or one of the benzodiazepine, so diazepam, midazolam. So, you need to look at your licencing cascade as well.

In a pre-med, or as a co-induction to reduce the induction agent needed. And in humans, we are told that it works as an amnesia, so they forget. We can't prove to cats and dogs.

We can't ask them, Hey, do you remember that? But we like to think that maybe they do. I don't have major beef with midazolam and Dad's ban, but they don't like it in really young, crazy patients, at higher doses, because I, I find they wake up and go a bit.

Dululu and I get scratched and I don't like it, but I think at lower doses, it can work well. I really like it for the older, the very, the very young, the very old, the very thick, it's nice, or just, yeah, slightly lower doses, so. I work with 5 anaesthetists who all have different opinions, and I love them all dearly and individually, but they all do things in slightly different ways to get the same very positive effects for our patients.

So we may be using, one person may use a certain dose and another anaesthetist may love that drug still, but use it at a quarter of that dose. Neither is wrong. This is why we don't.

Give out drug protocols because it should be tailored to every single patient. But yeah, in general, if a patient is reactive under anaesthesia, they're probably a little bit too light. So you should look at that.

And is it because you haven't got enough analgesia or sedation on board? And then it's working out the safety of your patient as to what drug is appropriate. So we can't sit here and say that X, Y, and Z will always be safe because it's going to be very patient specific.

I love your answer to that about not having drug protocols because we really should be determining what is best for each individual patient. I think that's a nice way to think about it. So I'm gonna take a little bit of a turn.

I've got an interesting question here, cause I, I feel like the longer we talk about local blocks, we might be stuck on local blocks for the remainder of the night. We're all excited about it. .

I see a question here asking about staging dentals, which I think might be interesting. Rachel, I'd really like to know your opinion on this. Do you have a take on staging dentals, so I, like if you have a big procedure doing two shorter procedures versus one long procedure, and there's a little tidbit at the end of the question that says regardless of patient ASA score, which I think is interesting, yeah, I'd love to know your thoughts on that.

So the concept of staging dental work is that in stage one, you, anaesthetize the patient, you examine your cavity, do your probing, your charting, take your X-rays, and then you perform your periodontal therapy, your ultrasonic scaling, plus a polishing if you're gonna polish the teeth. And that is, . You know how long that's going to take.

You know, you can set aside the time appropriately for that. Nurses, techs can get actively involved in that stage. And then you can take the information that you've gathered, the, your chart, your pathology that you've detected, and your dental X-rays, and then you can sit down with the client and say, This is what we found, this is what we need to do in the next stage.

And then the client is gonna have a much better picture of how much money they're, you know, gonna have to spend in the second stage. And also, you can, then hopefully predict a bit more, accurately how long the second stage will take. So I think there's definite benefit to that, in particularly in general practise, where, you know, we've all been in a situation where you're starting a, a, a quick dental procedure, and you're expecting it to take an hour, and then you anaesthetize it, and then you suddenly realise you've got 20 teeth to extract.

And then that one hour turns into a, you know, a 3 hour mammoth, situation. So there's definite benefits to it, . I'll give you my opinion on the, the kind of the, the safety of it, and, and then I'm, you know, very keen to hear Jodie's take on it.

We know, and when I talk to clients, there's a risk with every anaesthetic episode. The way I understand that risk is it's a separate, risk for each episode. It's not a cumulative risk.

So the fact that we anaesthetized the patient, you know, 2 weeks ago, in theory, shouldn't affect the, the risk for the next anaesthetic episode. And, and certainly in a, in a general practise situation, it really depends on how good you are at managing things like hypotension, hypothermia. If you're good at keeping your patients normothermic and normotensive, then, then, you know, go for a a long anaesthetic episode if, if that works for you.

Personally, from a surgical point of view, I know I get fatigued, mentally and physically. My hands get tired after maybe 2 hours of operating. And I know after 2 hours, I'm gonna start to get a little bit cranky, maybe a bit hungry, thirsty.

And then I'm gonna start to break roots and then it's all gonna go pretty horrible. So, you know, from a surgical perspective, I might prefer to have. Two shorter episodes than one long mammoth, dental procedure.

But sometimes I hear horror stories of, you know, 5 hour dental procedures, and I just think, why, you know, that's not gonna be in, in anyone's benefit. I don't think, to do that. But, Jodie, please, I'd love to hear your, your thought on the kind of 2 verses, 2 shorter ones versus 11 longer anaesthetic episode.

Yeah, I'm inclined to agree with you. The literature shows us that a longer anaesthetic will encounter more complications for that patient. No one's done the study comparing multiple anaesthetics to longer anaesthetics, unfortunately, but we do know that the longer the anaesthetic is, the more complications you are likely to encounter.

So I do think it's better to have shorter, anaesthetics if possible. I wouldn't recommend doing your staged procedures on consecutive days because then you've got consecutive days of starvation, etc. Which is not good for the patients.

We do want. A reasonable recovery period between them probably at least 34 days. But I, I do think it's sensible for the entire team and the patient to keep your anaesthetics to a shorter duration as possible.

But for us if our patient is stable under anaesthesia and Rachel's so happy to continue, we do continue to, we, we're not keeping them down to like 30 minutes. We will go 2 or 3 hours and obviously for the other procedures we're doing at the hospital that are more complicated and and have to be longer, we do go a lot longer than that. Where necessary, but minimising anaesthesia time is always an important thing.

I think as well from someone that helps deal with bookings and speaks to clients. Are they going to come back? It is something you need to think about.

So a lot of them, I think there's like 33 points I have in that. For me, placing my own pet under anaesthesia, these guys know I'm a nightmare. I have to really not be there.

I'm so emotionally attached to my pets. It's the end of my world when I need anything, even if it's a vaccine. So for me to get emotionally invested and to put myself on a selfish note through my animal going through an anaesthesia, I don't want to do that twice.

But I understand the arguments of why that might be better for them. It's just a lot for someone to potentially go through, and we know how attached a lot of people are to their pets, which is fantastic. Can they afford to come twice?

What's the pricing going on when you do stage? Is that affordable for people? That's something you have to think about as a clinic.

And some people may have had to be quite heavily persuaded to come in for that dental. They've come in, you've made them nice and shiny and clean. Everything looks lovely.

They can't see what's going on underneath, even if you show them the X-rays, so sometimes they think everything smells great, lovely. I'm not coming back. So there's the clinical side of like the dentistry, the logistics, and the safety of the anaesthesia, and then there's the reality of what the owners are going to do.

And you won't find that everyone will fill in the same box. It will be people will prefer different things, and maybe it's something you need to be offering and knowing it may not always happen. And if you are doing it as a stage, then really good follow up, really good follow up to make sure they come back and they understand why they're coming back.

Those are all really good points to consider and it's kind of it's it's nice to be thinking about it from obviously multiple sides, particularly the client side and kind of on that note, there is another question that just popped up is how do you present staged dentals to clients as far as costs because there are, you know, there you are incurring cost of a second anaesthesia. So maybe if you guys have any tips or tricks in terms of like what is the wording that you might use to discuss that with people. I guess it's slightly different where, where I work in a specialty hospital, but for first opinion practises that are doing it successfully, I know that they, often will make the total anaesthesia cost comparable to one anaesthetic episode.

So they're not, they're not penalising the client financially for doing two anaesthetic episodes. . That's helpful.

Definitely, yeah, and I think, I think also like you said, Rachel, when you're, it's really about managing people's expectations, isn't it? All so much of what we do is around communication and we, you know, you could be the best dentist or the best nurse or the best mathetist in the world, but if we're not able to appropriately communicate why or when or how or what then. No.

I mean, the days of, I mean, when I started in practise, it was a classic that you would have morning consultations, and then you would do your sterile, surgical procedures, your bitch base, castrations, whatever else that was nice and clean. And then you move on to the dirty surgery, which is obviously dentistry. And then you're supposed to go back to your afternoon consultations.

And that kind of model of, of slotting dentistry in, squeezed in like that just is not practical for, for general practise. More and more people, surprisingly enough, are getting into dentistry now. You know, dentistry's finally, you know, getting some traction.

You know, the cool people now are into. People like me who want to be Rachel Perry when they grow up. Oh bless you.

But the thing is that there are teams now. There are teams of nurses, there are teams of vets that actually are passionate about dentistry and like doing it. And practises should move towards giving those individuals the correct equipment, the right the right space to do dentistry.

Because in first opinion, In practise, you should be doing dentistry all day, every day, 5 days a week. And we probably still would not get through all the work that needs to be done for, you know, dogs and cats and rabbits and rodents in, in, in general practise. So, that's one thing to consider.

If there's any way you own your own practise and you can change the way your day is structured, that will, that will definitely help. Yeah, as well, like, this is a really good place to note that education is key. Like why should they have an anaesthetic to have dentistry when a groomer can do that for you for 50 quid.

We all know that's not right. We all know why. But education is key, and why would they know?

They, you know, they, their daughter got them a dog maybe to keep them company. They're not gonna know what we think is so simple. We need to remember that we got taught this once, so we need to pass that education on.

And that's when you can really rely on your nurses if you're still, you know, bless you, having 10 minute consultations. Because they came in for a lump or they're lame or they're coughing, and then you notice the mouth, the fractured tooth, the horrible mouth. There's not enough time to educate them, so use your vet nurses, use your nurse consultations, so that you can then say, I see that you're here for blah blah blah.

I'm quite worried about the periodontal health. Would you like a a nurse consult? It probably wouldn't be immediately, but maybe someone's free, but.

You know, plan that these dental consultations happen so they can talk you through the benefits of having appropriate dental care, the anaesthesia, everything, so that if you are then talking about staging, they're already educated as to why it's so important. And yes, I know fluffy looks so much nicer and shinier, but I understand there's a lot going on under the gum because. They've had that education from the beginning.

It's not a rushed, Here's a leaflet or a 10 minute consult where the last minute was, Oh, by the way, should have a dental in the next 3 to 6 months. That really destroys the importance of a dental. If it was like, I mean, you either need it or you don't.

If my dentist said to me, that tooth really needs to come out because, and explained to me and said, See you in 6 months, I'd be horrified. And if we had the amount of inflammation. And potential infection anywhere else on that dog on its head or its paw, you wouldn't be saying maybe we could do something in 6 months.

The owner would be wanting something now. It's because it's hidden by the lips, and, you know, we've been told historically that dog and cat breath is normal. It's not normal.

We know this, but the owners don't, so it rolls us always back to education and taking the time and really, I always try and see things from an owner's perspective. You know, I can't brush my cat's teeth. They're gonna need a dental.

That's gonna be stressful. Who can help me feel better about that? And that's the trained veterinary team who can pass on their education to you.

So, like Rachel, it's about the structure of how you do the dentals, but also how you support them pre and after, and nurses are really, really in a good place to do that. Absolutely, yeah, and that's a great place to implement nurse utilisation, right? You guys are brilliant and wonderful at what you do, and that's the perfect opportunity to be able to work on that.

So, OK, we have very quickly approached 9 p.m. I just looked at the clock and I was like, oh my, Kirsten, we are not keeping track of time.

If you lovely ladies don't mind, I might squeeze in one more question, and don't fret, there's a couple. That are kind of lingering on here, but what I have historically been able to convince Dawn to do for me is in our kind of post lecture email and kind of survey and things like that that goes out to people maybe potentially adding in a couple more questions if you guys don't mind typing some answers for me within the next week or so so we will, we can get to those, but if you guys don't mind one more question I might sneak one in. I just saw one come up about, even though we've talked in great length about not necessarily having drug protocols per se, I do see a couple people wondering about what your preferred types of pre-meds and an induction agents might be for your dentals.

So I would love for you to share that with us before we let you ladies go enjoy a very well-deserved, relaxing rest of your night. I would love to just, say one nugget about this because I feel like Rachel and Jody can give a lot more insight because I get told what to do, but I understand the drugs and it's a conversation because I can't prescribe. But for one of my recent lectures that I created, I had a patient.

I made up their history, I made up what they came for, and I gave 6 anaesthetists the same patient. And this brings us back to tailored pre-medication with the experience of the drugs you've used. And the drugs that you actually have available.

All 5 of them, 6 of them, sorry, came up with varying answers. Similarish, same result, the patient would have been fine with all. But my point being is that just because we say one thing doesn't mean you're wrong, but there's certain drugs that can be better, but at different doses.

So you will never find, even within one building. A complete concrete answer. So that was my little bit.

The more people you ask, the more answers you're gonna get. That's always my problem. All right, Jody, we'll let you, you're up first, sister.

Yeah, so, we, we are lucky that we work in a hospital where we have the time to fully assess each patient and come up with the table protocol. So I don't have a standardised protocol. We don't have any standardised protocols.

But there will be the, the more common protocols. So I'd say for a dental where you're expecting to be doing extractions or there's already inflammation, you need a good analgesic, and that's gonna be methadone, the majority of the time. Your dose is gonna depend on whether or not you expect to do local blocks, how painful it is, etc.

We tend to use below the licence dose, so usually between 0.1 and 0.3 MB per gig, depending on the patient.

And then your healthy patients, we're usually gonna combine that with an alpha 2 agonist, so either meatomidine or dexedatomidine. And again, we find that we achieve a good effect with very low doses. So if we're going IV for a pre-medication, we're using somewhere between 1 and 4 mcg per kilogramme of meatomidine.

So, really, really tiny doses that are actually off licence because they're below the licence dose range. I will go a little bit higher, between kind of 7 and 15, for the healthy patients, higher still if they are particularly highly strung. And then we might add in something like ketamine, for our premedication.

Very similar in cats as well. I go a little bit higher with the meatomidine or Dexed in cats tend to start 3 to 4 mcg per kilogramme, but really still tiny tiny doses, and tailor it to the patient. And in the kind of ASA 3 to 4 patients where maybe your alpha 2 agonist is not appropriate, I will usually just get opioid alone for the premedication.

In my hands, midazolam causes excitement, so I don't tend to include that in my pre-med. I save it for, coinduction. And I like that in my hands.

Rachel, I'd love to know what you, what your kind of thoughts are if they're along the same lines as these, these two. Well, yeah, I mean, I agree with what Stacey and Jody have said, you know, if I'm anticipating, performing an extraction, I'm gonna be inflicting pain on this patient. I'm gonna be cutting soft tissues.

I'm gonna be compressing, cutting bone. It's gonna be painful, and we know that the oral cavity in the face is very, very highly innervated, you know, so, . Even just one extraction of one tooth, I'm gonna be anticipating, you know, moderate pain associated with that.

Obviously, the better my technique, the less, you know, post-operative pain we can anticipate. So a good surgical technique definitely is gonna help. But in terms of drugs, certainly a pure new, agonist like methadone is gonna be helpful, plus your kind of, you know, your multimodal approach.

We're, we're getting some analgesia from our alpha 2 agonist. We're, you know, gonna be getting some. Analgesia from ketamine, if we're adding that in.

The one thing I would say, and this is from my kind of GP, background is just please remember that volatile, anaesthetics are not analgesics. You know, Stacey said at the start, there's no one kind of goal or there's not one tip I can give you for managing hypertension, but I would say just remember that volatile, agents are not analgesics, and if you're having to turn up your volatile, anaesthetic agent, then please add in additional, analgesia. And if you've started on the lower end of your methadone dosing, then, then feel free to to top that up if you need more, analgesic and do learn how to do nerve blocks because that will definitely help and try and get to a wet lab somewhere where you can practise them safely before you're, you're doing it on a live, live patient.

I feel like we're all in a company of people who are big fans of the local blocks. We're like, yes, please. Put them everywhere.

Yeah, Stacey's always on at me. Have you put your block in yet? Have you put your put your block in, I think I was gonna say communication about whether the blocks have gone in or not, when you're the one monitoring the anaesthesia, then you kind of know what kind of roller coaster you're riding.

Has it gone in but the inflammation was so bad that it's not been overly affected, so what's your backup plan there? And I would also say from my GP time of. Don't just keep using the same drug and giving more of it and expecting it to have the same effect if the top up didn't really work the first time, because, you know, you've given 0.2 me perhaps of methadone for your pre-med.

Your blocks didn't work as well, perhaps, you know, your vet isn't trained to place them. And that's OK, there's no shame, you know, encourage everyone to get educated together, that's fab. So maybe we might top that methadone up, but if that still hasn't done anything, if you just keep giving more, even though it may be licenced, that dog or cat is going to wake up high as a kite and highly stressed.

So multimodal is about using different amounts of drugs it's very small volumes and lower doses to avoid negative side effects, so. I think as well, if you ever have a case that you're particularly worried about or don't know what to do with anaesthesia or analgesia-wise, the team at North Down Specialist referrals are happy to give advice. You can always email and wherever you are around the world, a friendly and a friendly dentist will always be happy to help you.

And at Bertie's Boutique, we do have an event in October covering anaesthesia, analgesia, and nerve blocks. So if you're in the UK and want to come, we'd love to see you. Rachel and I are gonna be there.

So that's in October. You can find it on our website. But if you ever want free advice, you can always email Perry referrals and North Down specialist referrals to help you because as we say, if you're trying to change things, that's amazing, you should be so proud and you should be supported in that, and we're all very happy to have you here and to help you moving forward.

I feel, I feel so empowered. I'm like, was this a personal session targeted towards me? Thank you guys so much.

I'm gonna take the opportunity to sneak in and wind things up, or wind things down, excuse me. We really appreciate you guys being here with us tonight and thank you everyone for joining us again, you guys imparting your wisdom is very much appreciated. We will try and get to the last.

Few questions. I will try and find some sort of way to make a little summary email to go out to you guys if these if these lovely humans don't mind me bothering them a little bit longer this week, maybe get some typed answers to you guys, but again, a big thanks to our panellists, a big thanks to Mars for co-sponsoring this with us at Many pets. We're working really hard on trying to put out more for you guys.

We are here to support you, the vet. Team, if you haven't met us, if you haven't talked to any of the four of us, I think we're really fun, but we are always here to support you. So there's myself, Claire, Charlotte, and Jackie.

We always want to hear about what sorts of CPD that you guys are interested in, and there's lots of ways that you can do that for our vet nurses, we do have a many nurses club on Facebook, so if you are not aware of that, that is actually where we post all of our free. CPD that we're doing all of the cool ways we're trying to support vet nurses and we're always asking you what you want. So I'm with Stacey on this one.

Even as a doctor myself, I'm a big like yay nurse advocate, so we, we always want to be doing more for you guys. So definitely check us out there if you are not already on it. So thank you again.

We will let these ladies go relax, and then we'll get the recording up hopefully tomorrow courtesy of the webinar bet. So thanks you guys.