Nov. 3, 2025

🔓Your Game Plan for Brachycephalic Anaesthesia: Tips, Drugs, and Red Flags. With Dr Abbie Tipler

🔓Your Game Plan for Brachycephalic Anaesthesia: Tips, Drugs, and Red Flags. With Dr Abbie Tipler
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Season 1

Did you know that a brachycephalic dog with BOAS has a 433% higher anaesthetic risk than a dog with a normal nose?

Let me rephrase that: that Frenchie you’re spaying later this week is more than four times more likely to die on her surgery day than any of your other patients. 😳

 

Do we have your attention?!

Thanks mainly to the rising popularity of the French Bulldog, you’re probably anaesthetising these kinds of patients all the time.

So how do we reduce that risk? How do improve patient safety while decreeing your stress levels?!

At the Brachycephalic Care Unit, surgeon Dr Abbie Tipler and her team have polished brachycephalic anaesthesia down to a fine art, and in this episode, she shares all the gold.

From the days leading up to anaesthesia to selecting the safest mix of premed and anaesthesia agents, all the way to a calm, well-oxygenated recovery, this episode is the ultimate masterclass in brachycephalic anaesthesia.

 

Hit us up for the full show notes for this episode, as well as Dr Abbie’s brachycephalic pre-surgery history template, here. 

 

This episode is one of more than 600 from our subscriber-only clinical podcasts. If you like this style of learning, where I dig for all the pro tips and updates from some of the best specialists in the world, then you’ll love our clinical feed. Go check it out at thevetvault.com

 

Oh, and if you’d like to join me in Japan in February or the Maldives in April for the most fun you’ll ever have at a vet conference  - have a browse at vetsontour.com

 

Topics Covered:

Before the big day

  • Structured history taking: airway, gastrointestinal, sleep, and anxiety indicators
  • Understanding the link between upper airway obstruction and GI dysfunction
  • Assessing regurgitation, silent reflux, and aspiration risk
  • Pre-treatment protocols: omeprazole, metoclopramide, and diet adjustments
  • Identifying when to delay elective procedures for optimisation
  • Using C-reactive protein and radiographs to assess for aspiration pneumonia
  • Managing anxiety pre-hospitalisation with trazodone

Plan for the day of surgery

  • Fasting times and timing surgeries for optimal recovery monitoring
  • Strategies for minimising stress in brachycephalic patients pre-op
  • The role of early premedication and pain relief
  • Drug choices: the “Goldilocks” approach to sedation
  • Reducing regurgitation risk
  • Your pre-op pro tips
  • Extubation and recovery: positioning, monitoring, and oxygen weaning
  • The impact of cage-side nursing and owner-assisted recovery

 

Click here for comprehensive show notes for this episode that includes sedation and anaesthesia protocols, as well as Dr Abbie's history template.

Free and Low-Cost Strategies to Improve Brachy Outcomes

Improving outcomes for brachycephalic patients often relies on meticulous planning, communication, and procedural adjustments that are primarily based on time and attention rather than significant financial investment.
The key to these strategies is performing a thorough risk stratification for every patient, recognizing that minimizing stress and ensuring preparedness are critical factors in reducing the high risk of intraoperative and postoperative complications.
Here are free and low-cost strategies to improve brachycephalic outcomes:

1. Comprehensive, Low-Cost Risk Assessment (The History)

The most valuable, low-cost tool is a structured history taken face-to-face with the owner, which allows the practitioner to gauge the severity of the patient's condition and tailor the protocol accordingly.
  • Focus on Airway Function: Ask specific questions to determine if breathing issues are present, recognizing that owners often perceive severe signs as "normal for the breed".
    • Determine exercise tolerance, asking how long the dog can happily exercise (ideally half an hour) and how long recovery takes afterward. A requirement to stop or turn back after 5 or 10 minutes is a red flag.
    • Inquire about airway noise (with or without exercise) and snoring.
    • Ask if the dog ever changes color or has had episodes of collapse or blue gums.
  • Assess Gastrointestinal (GI) System: Given the strong link between airway and GI problems (aerodigestive disease), assess for issues that increase regurgitation risk.
    • Ask about overt regurgitation.
    • Look for signs of silent reflux (hacking, lip licking, neck extension, or waking up suddenly from sleep).
    • Ask about difficulty swallowing or eating or excessive salivation.
    • Determine Stress and Sleep:Ask if the dog wakes up suddenly or sleeps excessively during the day, indicating potential sleep apnea.
    • Gauge the patient's anxiety levels when away from the owner, as high anxiety is a significant risk factor for complications.

2. Environmental Management and Stress Reduction

Reducing anxiety is considered one of the most important aspects of treating brachycephalic patients. Many stress-reduction tactics involve simple environmental or behavioral adjustments:
  • Reduce Stimulation: Keep the patient in a quieter or darker area of the hospital.
  • Comfort Measures: Encourage owners to bring the dog's favorite toy or blanket.
  • Handling Techniques: Avoid specific handling that the dog dislikes (e.g., touching their feet).
  • Early Intervention: Administer premedication and early pain relief quickly upon arrival so the dog is not sitting in the hospital getting stressed. Early pain relief reduces stress, panting, and oxygen requirements.
  • Owner-Assisted Recovery (Free, but requires protocol change): Allow the owner to come and sit cage side with their pet during recovery. This strategy has been linked to much lower complication rates, including a 0% mortality rate in one unit, because it drastically reduces stress and the need for heavy sedation.
  • IV Catheter Placement: Use Emla cream when placing the IV catheter to reduce stress.
  • Temperature Control: Keep the patient in a warm space during preparation and recovery, as shivering increases oxygen requirements.

3. Procedural and Timing Adjustments

Effective planning ensures the patient spends less time under general anesthesia, reducing the risk of complications.
  • Schedule Early: Schedule surgeries early in the day to reduce the fasting period and ensure the patient is recovering when staff is at maximum capacity, avoiding complications during evening handovers.
  • Avoid Prolonged Fasting: Avoid long periods of fasting. If the dog is a frequent regurgitator (especially when hungry), instruct the owner to give a very small meal (e.g., a tablespoon of food) three to six hours before anesthesia.
  • Use Checklists: Use a pre-induction checklist and a long, detailed plan outlining necessary equipment. This ensures full preparation before induction, preventing delays while the patient is under anesthesia, thereby minimizing anesthetic time.
  • Preoxygenation: Perform five minutes of preoxygenation using flow-by oxygen (and a mask if tolerated) before induction.
  • Tube Selection: Have a good selection of ET tubes ready and often choose a slightly smaller size to avoid jamming or trauma to the larynx/trachea.
  • Recovery Positioning and Monitoring: Ensure the patient is in sternal recumbency with the head slightly elevated, neck extended, and tongue pulled off the soft palate during recovery. The nurse must be cage side and monitoring the patient (including $\text{SpO}_2$ and temperature), avoiding a "set and forget" approach in an oxygen cage.
  • Prepared for Emergencies: Have suction, a laryngoscope, an ET tube, and induction drugs (like Alfaxan) readily available to quickly re-anesthetize the patient if an obstruction occurs.
Did you know that a brachycephalic dog with Boaz has a 400 and 3030% higher anesthetic risk than a dog with a nose?Let me rephrase that.That Frenchie that she's paying later this week?She's more than four times more likely to die on her surgery day than any of your other patients.
Have I got your attention?The reality is that thanks to the rising popularity of Mandy the French Bulldog, you're probably doing GAS in these sorts of patients all the time.So how do we reduce that risk?How do we give your adrenals a bit of a break on the days that you have to anesthetize an anxious chunky Frenchy?
Or even more so if you are part of a theme that does airway surgery in brachypatients?Dr. Abby Tippler is a surgeon who does a lot of surgery on squishy faced dogs at their brachycephalic care unit in Brisbane.They've polished the brachycephalic anesthetic down to a fine art, and in this episode, she shares all the gold from the days leading up to the anesthetic to selecting the safest mix of drugs and making sure your patient wakes up calmly and well oxygenated on the day of surgery.
This episode is the ultimate master class in brachyophalic anesthesia, which is why I wanted to share it with you.This episode is one of more than 600 episodes from our subscriber only clinical podcasts.If you like this style of learning, where I dig for all of the pro tips and the updates from some of the best specialists in the world, then you will love our clinical feed.
Go check it out at the eventfall.com.Just click on the clinical content button.Our subscribers also get detailed show notes for each episode to use as a reference.I'm happy to share the show notes for this episode with you, including Doctor Abby's pre op Brackish phallic history template.I've put a show notes link in the show description for you wherever you're listening right now.
Tap on that and we will get those notes to you.OK, here is Doctor Abby Tipler with a plan for safer brachycephalic anesthetics.Enjoy.So how I'd like to approach this episode, it's from the perspective of a brachycephalic comes into my surgery and potentially GP because we see them all the time and it's going to come in Forest Bay or a dental or a lump removal or something I need to do to it and knock it out for.
And I'm aware that they are.Well, I'll let you know.Are they different?Do we need to treat them differently?Do we need to do different things?And I know as the maker of the podcast, throughout the years, every now and again we'll tackle a topic and the brackets will come up as a caveat or as a special case scenario.
So the ECC guys will talk about pro kinetics and there's all these little things.And what I'd like today is to put all these little things in one box to say here's a good plan to get your Brackie through the hospital visit, procedure, anaesthetic and out the door with minimal chance of a disaster.Yeah, absolutely.
And I think, you know, to answer that, are they different?Well, yes, they they certainly are very different and we know that they have a about a 1 1/2 times higher likelihood of having an intraoperative complication and about four times more likely to have a post operative complication.
So they are different and there are some special considerations when it comes to to managing those cases and and that really does start with taking a history.So that's definitely a place that we can start in terms of setting ourselves up for success.
OK, so should we start with the history?What do I need to know in my history other than your squishy face?Yeah.OK.So my history with these brachycephalic patients tends to be very structured and there's typically sort of three different things that I really want to know about this patient that comes to see me.
So the first thing you know obviously is how are they managing in terms of their Airways.Now one of the things actually that I'll touch on is that brachycephalic owners, they as we know, they think that all of the signs that they are seeing in their dog are normal or normal for the breed.
And often they've become very habituated to all sorts of, of abnormal behaviours, but they think that they are normal.However, the other thing that I've noticed is that they don't tend to, to lie.They don't sort of say, you know, if you say, does he snore?
They don't, they don't say no.They, they say, oh, yes, yes, no, he definitely snores.And you know, I don't really take him out for walks because he, he can't manage.And they sort of say this like it's completely normal, but don't make things up.So you can actually get a really, really good idea of how the dog is coping just by asking the right questions.
And I'll share my history taking template with you for the listeners as well.But essentially, I'll ask about how much exercise the dog can tolerate.And I'll specifically ask them the difference between a hot day and a cool day.
I'll ask them if they go out for that walk, how long will it take them to recover?So what I'm wanting to see is, is a dog that can happily exercise for half an hour or so and can come back and, and doesn't appear like it's about to sort of, you know, get itself into trouble.
So if that's saying, you know, 05 or 10 minutes and then we have to turn back or take a break or that's a little bit of a, of a red flag.So there being a problem with the airway, I asked them about airway noise.Do they have noise without exercise?
With exercise, obviously, How do they snore?And then I move to do they notice with exercise or without exercise potentially, do they change colour at all?And obviously this is a bit of a subjective thing, but if you don't ask the question, you're not going to get an answer.
And then, you know, have there ever been any episodes of Collapse or the gums being bluish in colour?And usually I know the answer to to that based on whether or not they can tolerate exercise.Because usually if they say, oh, he can run around in the dog park for a couple of hours with no troubles, then it's unlikely that they're going to have too many episodes of collapse.
So you're not just assuming because you're Brexyphalic.I'm going all in on the Brexyphalic protocol.You are still trying to stratify risk based on this particular dog's presentation, based on what the client tells you.Yeah, exactly.
So and the reason why I'm trying to get a really good assessment of this patient is for a couple of different reasons which I'll actually get to.So airway I guess is step number one.Now the second group of questions that I'm asking about is in regards to the gastrointestinal system.
So I'm not sure if you've heard of the term aerodigestive disease, but I really like that term because it really links the two together.So we know that rockycephalic dogs are very, very prone to all sorts of gastrointestinal problems.
They have a sort of a floppy esophagus with typically with poor motility.They often have a larger esophageal hiatus, especially French Bulldogs, and this can lead to hiatal hernia, which is where that gastroesophageal junction can sort of slide in and out of the chest.
And of course, this all increases their propensity to regurgitate or in some cases vomit.And the reason why it's often linked to the the Airways is that they may have these underlying primary gastrointestinal abnormalities, but then if they also have increased upper airway pressures, then that subsequently leads to a decrease in intrathoracic pressure.
And then that kind of sucks everything cranial in terms of the ingested contents that might be kind of sloughing around in in their esophagus or stomach.So it's really important to to ascertain how the dog is doing in terms of its gastrointestinal system and I'll explain why in a second.
So.We want to find out about your respiratory tract and we want to find out about your GI tract.The 2 are kind of linked as well as you said.Yes, and the yes, so the two are linked.So then I'm asking questions about, you know, is the dog regurgitating?And I'm also looking for signs of silent reflux as well.
So that's often where they'll sort of be running around and they'll start to kind of make that hacking sound or there might be a lot of licking their lips extending out their necks is another one.So there's a few signs that they might be silently refluxing as well.
Sometimes waking up suddenly from sleep is another sign that they might have some silent regurge.And then I also asked about swallowing as well.And this just adds to that overall picture in terms of severity of the obstructive airway disease.
So often you'll find that they salivate a lot because they can't swallow and exercise at the same time.And sometimes you'll find that they have difficulty swallowing and eating as well.So I'm getting a bit of a gauge on whether or not that's an issue.And then finally, I'm asking about sleep.
So I just like to have a bit of an idea.Do they wake up suddenly?Do they sleep a lot during the day?And that's to give me a bit of an assessment of how well they can actually breathe through their nose and whether or not they've got signs of of sleep apnea.Well, little things they have that that do have issues, don't they?
They have problem children.Yes.So they're problem children, but I think having a bit of an understanding of how severely affected the patient is in terms of their especially their Airways and their gastrointestinal disease can help set you up for potentially making some changes free the dog coming in and maybe potentially on the day as well.
Another important thing that I will add in here is I like to get an idea of how anxious the dog is away from the owner.So if they say to me, oh, look, he's, he's never left my side.And when I go out for half an hour, he becomes very anxious and I come back and he's in a real state with his breathing.
Then that's also a very important thing to know because, well, for a start, brachycephalics with high levels of anxiety that that can be a risk factor for complications.But secondly, you know, that's exactly what I'm planning on doing is taking the stove away from the owner.
And you know, am I in a position where potentially I don't want to do that?Can the owner be present for part of it?And I'll get to that as well.So what are my goals in terms of asking all these questions?And it's 2 fold.
So the first is to get a little bit of an idea of how risky the, you know, whatever procedure that I'm planning on performing is going to be.And the second is all, are there things that I can change in terms of my protocols to reduce the risk of complications?
And for the situation where the surgery doesn't have to be performed on the same day, can I pretreat the patient to get it into a better state before carrying out my planned procedure?So obviously, if it's a fracture repair or it's got a large sort of wound or something, then you may not have the luxury of being able to pretreat it.
But if it's a spay or a dental or some other elective procedure and you know that it has a severe frequent regurgitation or severe brachysphelic obstructive airway disease or a combination of the two, then this may change decision making around the case.
Yep.So Abby, this history, are you sending it to your clients beforehand if you can, if you if it's a, a planned surgery or are they doing this at home?Or is this a you're chatting to them in the consult room?Yeah, no, absolutely.I'm chatting to them within the consult room.I don't really find personally that questionnaires are as beneficial.
I find that often the way that they deliver the information gives me a really good sense of severity.So you know, a lot of these things that I'm asking them are sort of semi subjective, so I really want to see how the owner's asking the question and also, you know, do I need to probe them for a little bit more information?
So it's definitely a face to face and it does take, you know, 10-15 minutes of course to go through these questions.But I think it's really important for these sort of higher risk patients and we know they're at a higher risk.So there's a couple of things that we know are potentially risk factors for brachycephalics needing surgery.
So one of those is if they require oxygen as admission, that's a bit of an obvious one, but you know, an anaesthetic is going to make that dog potentially worse.And so if it's requiring oxygen, even if it has really other really severe signs of brachycephalic obstructive airway disease and you're planning on performing a dental, you know, could that dog benefit from airway surgery first, if it's very anxious, that can be an additional risk factor.
You know, in terms of, well, what do I do for anxious dogs?Well, there's a bunch of things.And in fact, we might talk about that in a separate little section because I think that's probably one of the most important things with treating these brachycephalic patients is to reduce their levels of anxiety.And a lot of them are anxious, aren't they?
They certainly in my experience, they they seem to be little stress heads.Yeah, they are.And I think, you know, maybe it's, it's that there's a, there's a certain type of loner perhaps that that chooses these breeds and, and often they are very, very attached to the dog and the dog's very attached to the owner.
So they, they do tend to be quite anxious.And there's also a thought as well that that's if they're suffering from brachyophilic obstructive alloy syndrome, that that can actually increase their levels of anxiety as well.So, so that's a very, very important consideration.And then a dog that's frequently regurgitating that is certainly a risk factor.
And so we want to be looking at ways that we can treat that patient prior to surgery, OK.So your risk breeds are your can't breathe, I'm a puka, I'm a stress head.Those are the ones that you're going to watch out for.Yeah, that's basically it.
Yeah.And there's a few others that are that pertain specifically to airway surgery, but you know, we're talking about brachycephalic patients in general, not specifically airway surgery.So which patients are going to benefit from some sort of pre treatment?
So the first ones are the ones that are the frequent regurgitators and typically I will try to get that under control as best I can prior to whatever the procedure is that I'm performing, but especially if that's airway surgery.
One other thing that I will note is because the gastrointestinal signs that are so intimately related to the airway signs, I know often with my airway cases that until I address that airway, I'm not going to have any hope in resolving their gastrointestinal side.
So I'm not delaying that for too long.But I'm often treating with something like a micposole at around sort of a mic picky BID for a few days or there's actually a new long acting and micposole that can be compounded from BOVA, which can also be quite useful.
And I think probably decreases the vomiting that I've seen, which sometimes you will see with omeprazole.And if if they vomit with omeprazole, which is obviously different to regurgitation, but if they vomit with omeprazole they do get them to stop, OK.Is how long is long acting?Do you know the the compounded?
One so the long acting lasts for five to seven days.So it can be very useful if if I'm seeing the patient at the right interval before the airway surgery, then I'll consider the long acting that of course, it relies on seeing them five days before or or whatever to be able to get that in.
So occasionally if they have very severe cases, I'll also add in some medococtromide at around half and make the keg as well BID and I'll give you all of these doses as well.Thanks.The other thing that I find can sometimes help is to get them onto a low fat gastrointestinal diet.
And I think how this helps is that when it's it's lower in fat, it it passes out of the stomach sodas.So potentially can help a little bit with the regurgitation and that can sometimes help them a little bit as well.So if I can get there regurgitation somewhat under control before surgery, then obviously that's that's better because what we are trying to really avoid and I'll talk more on this, but we're really trying to avoid a lot of regurgitation in hospital, which of course has been the risk for aspiration pneumonia.
Just as another small thing, if I've got a a frequent regurgitator, I will often get the owner to give a very small meal around 3 to 6 hours before I plan on anaesthetizing them.There's a little bit of research around this.
It doesn't specifically pertain to brachycephalic dogs, but I think certainly in the human world as well, they've moved away from these long periods of fasting.So especially if the owner says to me he regurgitates when he's hungry, that would be the one where I'd get them to make that extra effort to feed.
Maybe just a tablespoon of of food a couple of hours before they set off for the surgery.OK, I try to avoid really long periods of fasting with, with my brachycephalic patients.And also on that note, I will often, and not just for that reason, but I will often try to perform any brachycephalic surgeries early on in, in the day so that a, that fasted for a, a lesser period of time.
But then B, obviously if there is problems in recovery, we're not dealing with Duff handouts and whatnot into the evening.So the second thing that I will always treat for if there's indications in the history and often I'll combine this with some thoracic radiographs.
But if there's any evidence of aspiration pneumonia, then this really should be pretreated before sympathized.It can be very risky anesthetizing a patient with aspiration pneumonia.And if there is any chance that they can be treated in advance, then obviously that's going to be highly preferable.
And obviously I've got the luxury of liaising with our internal medicine team about the the treatment and, and helping me interpret the radiographs, et cetera.So, so are you, are you are you basing that maybe on just on history of how much are you regurgitating or or are you, is it based on physical examination of your chest sounds clear or are you, are you X raying?
That's interesting.Heavy pukers, though, like how are you deciding?Are you maybe, do you maybe have pneumonia?Yeah.So usually they, they're also coughing.So, and it's a little bit of a different, I, I tend to find it's a little bit of a different sound to that tacking that's more of a throat irritation.
So it's, it's more of a cough.Sometimes they're unwell, but certainly not always.I, I, I find that there's a lot of brachiocephalics that can have this chronic low grade aspiration and they're not necessarily, you know, sick with a fever.Sometimes you can also run ACRPC Reactive Protein I.
Was going to ask you that.It's very non specific, but it can give you some indications that there's some inflammation going on because you won't always detect aspiration on radiographs.And the other thing is you always have to assess the risk of taking those radiographs as well.
So I did recently have a patient that was a frequent regurgitator and it had had a previous history of aspiration.It was now coughing.I had airway surgery planned.This dog was going to continue to get bouts of aspiration pneumonia without the airway surgery.
So it had to be performed.And it was a very, very stressed, anxious dog.So I actually opted to pretreat with antibiotics.I don't usually do this.Obviously we need to be very careful with our use of antibiotics, but I did decide to pretreat this dog with antibiotics without confirmed evidence of aspiration.
So just based on it's history of previous episodes of Aspiration, the fact that it was a frequent regurgitator and the fact that it was now coughing.You're right because it it does sound, I didn't think about that.But X-rays, you want to check if it's safe to sedate.So you have to sedate it to take X-rays to see if it's safe to I see what you mean or you've got to put it.
Put it down.And trace it out and then it regurgitates.It aspirates while you're taking X-rays.That's exactly it.That is exactly it.So, you know, in those situations, the alternatives are potentially to give it something that's fairly safe like Trazodone and maybe, you know, a little bit of a reversible sedative like metatomydine.
You, you, you that's going to be pretty safe to take some radiographs.But the question is do you go to that extra effort?And, and of course, most of the time you do because we want to have a really good understanding of what's going on.But potentially if everything screaming aspiration pneumonia, then you could just treat.
So aspiration is another one, obviously, that I pretreat.The third thing that I think is really, really important is if it's a highly anxious dog, I will send the owners home with Trazodone to give on the morning of surgery.And I find that that's really, really helpful.
I usually pick a dose of somewhere between 5:00 and 10:00 mix per gig.Sometimes I'll get the owner to test it in advance just to see the level of sedation if I'm really, really worried about the anxiety levels of the dog.But I think it's really important for these patients.
And I can I just say this is a it's already a lot before you've even done anything.Are clients open to this or are they like what you've spent all my money when you haven't even touched?Like, you know, we don't even add surgery.No, no.I mean, I think yeah.Oh, look, I absolutely think they get it.
I, I mean, they're already coming in for the consult anyway.So the only extra additional cost, you know, may be a Trazodone and omeprazole.It's I don't think that that's of affected enemy.Obviously I'm lucky in that a lot of the, the pet owners that come to me are not financially constrained.
However, you know, I think most of the time if there's something that can potentially reduce the risk of a complication, owners are pretty happy to to take that up.And I mean, also remembering that complications tend to be very, very expensive.So if we can we can avoid them in any way, then obviously that's ideal.
I'm trying to make that practical because you're right, the it's definitely you have a biased case selection.They're going to be the sicker ones.The dog that's going to come in for its routine procedure with me is not necessarily going to be that bad.But I like this conversation to say before you book in that dental, do have this conversation again, identify the risk ones where you may want to do these things and explain to the owner, I don't want to kill your dog with the dental.
So here's why we're going to do a couple of extra things beforehand.Yeah.Exactly, and you'll be pleased to know as well that there's a few things coming up which are completely free of charge that you can do to reduce the risk.A big interruption to give you an update about Bets on Tour, the epic conference company that I joined earlier this year.
Our Japan's key conference is about 75% sold out.So if you were thinking of joining us in the snow for our ECC slash surgery slash imaging focused CPD content, get on to it.That is from the 24th of February to the 1st of March 2026 in Nozawa Onsen.
And if snow is not your thing and you're more of a warm water, cocktails by the pool and epic surf person, then maybe you should check out our Maldives conference.Actually, I was telling a French speaking person about it the other day and she nearly had a heart attack.When I call it Maldives like the Australians do our Maldives conference.
We just released the final academic program on the website at Vets on tour.com this week.But to give you a sneak peek, here's what the average day will look like.Sunrise surf, some medicine.Breakfast.Surf or dive or fish, some surgery, some medicine.Dinner, cocktails, bed.
It's a tough life, but somebody's got to do it.We'd love to see you there.Go check it out at Red on tour.com.OK, back to Doctor Abby The.First thing is stress management.So anything that we can do to reduce the stress of that patient, we want to do.
And look, all hospitals don't necessarily have the luxury of having a separate room for the brachysophelics or area.But if you can, if you do have that luxury of keeping it in a slightly quieter area of the hospital or a slightly darker area of the hospital, or sometimes they like having some music playing from an iPad or something.
So, and that's also something that the owners may be able to give you a few clues on.So, you know, if they don't like their feet being touched, don't touch their feet.If there's a toy that they specifically like or a blanket, get the owners to bring that in with the patient.
So anything that we can do to reduce the stress of these patients, we want to do.The other thing is if we can premedicate them fairly early, so ideally we don't want them sitting in the hospital all day getting very stressed.
You know, they may have Trazodone on board.If they don't have Trazodone on board and as soon as you admit them to the hospital they seem very anxious, then often those patients we will administer some Trazodone in hospital and then we get them early premedication and also early pain relief.
So if there's any indication that they are in pain, then we want to treat that quickly as well.That's going to reduce their stress levels, but also potentially their panting and oxygen requirements as well.Can I ask there with the premed, are we going to come to which drugs you're using for your anesthetic or is this a good place to?
Absolutely.What are your premeds?Or am I jumping ahead?Yeah.No, no, no.It's a good place to ask.So I like dexaminotomidine or metatomidine, both of them are reversible.They are quick acting, they're very reliable.In terms of what sedation, we can typically expect a dose dependent.
So a higher dose gives a higher level of sedation and we don't get any laryngeal dysfunction.So it's it's a fairly safe drug and and we probably use it at much lower doses than, well, certainly what I used to use in general factors.
I'm horrified to think what I what doses I used to.Use now.When it first came out, we gave those big doses.With chart, yeah, yeah.I mean you just you, you, yeah.I mean you went off the charts so you felt like you were doing the right thing.And I mean, gosh, it's certainly sedated them, that's for sure.
But you know, we've, we're using tiny doses and the doses that I feel probably take the edge off, you know, enough to get a catheter in that aren't knocking them flat like they used to.So the dexmedotomidine, the dose we use is somewhere between 2:00 and 4:00 mics per kilo.
And then we're also giving an opioid in most instances.And if it's a short procedure like radiographs and it's not painful or potentially even a dental scale and Polish, you could use but Butrophenol, So Vitrophenol as we know, it's a little bit shorter acting, but it does have a a slightly better sedating effect.
So also really good for those brachies that come in and they are heat stressed and in trouble.But most of the time with my procedures, I'm using methadone and I'm using that at a dose of .3 mix per kick.But certainly I'll give you a accompanying notes with all of these, these doses.
I just want to double check so that two to four mics per kilogram, is that the dex Dermatomidine?That's dex metatomidine.So metatomidine is double the the dose.It's it's double the strength, but it's the same volume in mills.
Yeah.So you do have to be a little bit careful that, you know, if you have dex metatomidine and metatomidine at the same practice that, you know, you're just double checking your doses, right?You might say, well, you know, why are we trying to reduce anxiety?
And maybe I'll just talk a little bit about what my goals are for ricocephalic patients on the on the day of a procedure.And it can be broken down into reducing stress, reducing regurgitation.And those two are very, very intertwined because they regurgitate when they're stressed.
And if they regurgitate, they get more stressed.And then the final thing is just being very, very careful with drug choice.So I often kind of joke that it's the only time a surgeon has to worry about pharmacology is with these brachycephalics.
If any patients going to have some sort of a drug reaction, in my experience, it tends to be a a brachycephalic dog.So I often won't give them drugs unless there's a clear indication for it.So I, I stay away from the, well, let's just give them a bit of extra opioid just in case they're painful.
I'm really looking to see and, and ascertain, you know, how painful is the procedure?Does it need a top up of the opioid?I'm not necessarily just giving it as a standard every four hours or whatever it is that I usually might do with with another patient.Yes, it's very much a fine balance of saying make sure you you give enough drugs because you don't want them sitting, stressing and recurring, but also just enough Goldilocks drugs, not any more than you need.
Yeah, well, this is exactly it.We know that opioids, for example, can cause cardiovascular depression.There was actually one study which found that lots of opioid top UPS increased the risk of the procedure.But then on the flip side, we really want to avoid pain as well because pain can lead to the becoming very stressed and tachypnea and then they can regurgitate.
So it is a fine balance.And again, on the stress front, you know, we don't want them to be stressed, but then we also don't want them to be over sedated and we don't want them to regurgitate.But then sometimes drugs that can potentially help with regurgitation like omeprazole, they they might vomit them.
So I mean there's all sorts of considerations when it comes to you know, which drugs and and the doses and just you know, really thinking through these cases on the day.So we are really carefully considering at drug doses and use on the day of the procedure.
So just on that as well.So in terms of potentially reducing regurgitation, I will often give a dose of Morphodent at a Migpicig intravenously at the time of IV catheter placement.
And they have also found that this reduces the isoflurane requirements as well under anesthesia.So, so that's the second advantage.Yep.If I have a patient in for airway surgery, I'm often also putting it on a continuous rate insulation of metaclopromide at a dose of amici per 24 hours, but typically I wouldn't do that or any of my other procedures.
Why are you more concerned about, well, not regurgitation, but pro kinetics with the airway surgeries versus the others?The reason I ask is I I interviewed Dr. Clay Sharp about pro kinetics and she said any brachyophilic in her hospital is getting a pro kinetic of some sort.
She doesn't care what it's in for, it's going to get it.It's very much that those are now 5 risk patients for recovery.So I really don't want the regurgitating over their brand new airway soft ballot warrant.Yeah, so, so yeah, perhaps I'm a little bit more paranoid with those ones, but certainly the others will get neuropodent and azimeprazole intravenously.
And of course if I've got a frequent regurgitated then it's probably been pre treated as well all.Right, that's all pre Med.So now our patient is ready for surgery.Is there anything else pre pre surgery or are we at what?
Obviously not going to talk about the actual surgical procedures yet, but the anaesthesia itself.Have you got preferences?Yeah.So we're ready finally to anaesthetize the patient or we, well, we thought we were, but hold on, there's another step.So one of the things that we absolutely know, and it's so interesting if you look at virtually any paper and that looks at complications of a procedure and then you look at what are the risk factors.
So, you know, can we predict based on, you know, whatever it is, which patients are potentially at a higher risk for, for a complication?And virtually all of them, it finds that a longer anaesthetic increases your risk of complications.And so this doesn't mean you know, rush through the dental, it doesn't mean you know, sort of try to, to perform the a very hysterectomy in, in record speed or anything.
But I think the key is to just be fully prepared for the procedure.So my nurses have a very long detailed plan which outlines exactly what equipment I'm going to need.So I'm not waiting for things when the patient's under anaesthesia.
So getting really, really fully prepared.And of course, I'm a big checklist fan.So we have pre induction checklists which just make sure, do we have everything that that we need?Are we performing the procedure that we said we were going to?
Is there anything else that's been all that needs to be performed in the patient's under etcetera, etcetera.So we're ready.We've got it as good as we can get.And that's one of the things that I often say about brachycephalics.We're not going to be able to not potentially get them perfect before anesthesia, but if we can get them a little bit better and in in better shape for the procedure, then that's ideal.
We've got a patient that's not stressed.It's been premedicated, it's been kept in a quiet space.And then there's one final thing that we're going to do before we induce.What might that be?Am I allowed to quiz the?Yeah.
So before we.Induction.What are we going to do to that?Pre oxygenate?Yeah, give a.Question, yes, so yeah, so 5 minutes pre oxygenation that that's really, really important.I mean potentially for all patients, but especially for these brachies, they fellow patients obviously.
OK, so that's sitting on the the table where you're going to knock them out.Nice and chilled, nice and sedated, flow by oxygen.Exactly.Yeah, fluid by oxygen and mask if they'll tolerate it.Yeah.One other thing that I forgot to mention as well when we're placing the IV catheter to help reduce stresses is just using amylocrine as well.
Very just a simple thing.And most of the time we we do that for all of our patients.But again for for your brachypatient, all of those little things can be important.So, OK, so we're pre oxygenating for 5 minutes and the other thing we're keeping the patient warm.
I mean, not the factor Thermia is probably more of an issue intraoperatively and postoperatively.But if we can keep it in a fairly warm space as well, because if it's shivering then that's going to increase its oxygen requirements.We want to have a good selection of tubes to hand.
So, you know, sometimes we can have a difficult intubation or obviously some of them can have a hyperplastic trachea.So we may not get the tube size that we want into the trachea.And I really don't like any kind of jamming of the, of the tube down the trachea if I'm feeling resistant.
So I'd much rather have a smaller tube that's nicely cuffed.So I'll often go, you know, just a little bit on the smaller sized so that it's not causing any trauma to the, to the larynx or trachea.And then we're using induction drugs that have minimal interference with laryngeal function.
And I mean, clearly I'm not an anaesthetist And my typical go to for these patients is, is Zalfaxan, which I know doesn't interfere with laryngeal function and tends to have that reliable induction that I'm, I'm used to using it.So I'm, I'm confident with, with that drug.
And I, I avoid ketamine in one paper and it was related specifically to airway surgery, but it seemed to be a respectable complication.So that's one that I, I typically don't use an induction anyway, but I would potentially avoid that anagrocephalic patient.And then in terms of the actual anaesthetic itself, again, you know, not being an anaesthetist, there's no special tips.
If anything, I find that while they're under anaesthetic, we've got a good access to their, to their Airways.And for most of the procedures that I'm performing, it's not the actual intraoperative period where there's a problem.But obviously, you know, you have all the all the usual monitoring and contingencies for anesthetic complications, which is probably another entire talk, you know, within anesthesia, but you know, carefully monster anesthesia.
And then the next phase that that I want to chat about is the recovery.So tell me if I've missed anything up until now so.No, I think that's great.I just had one question about.Yes.The premade still we didn't mention ACP at all.
Not a thing anymore in general or specifically for the brackies.Yeah, absolutely.I mean for the brackies, it's not my first go to because it's not reversible.So if they are over sedated then I can't take that back.So that's why I tend to prefer metatomidine.
And the other reason is because I'm often using small boluses of metatomatine in recovery as well.And again, it's reversible, so I can always kind of alter things as I go along.There may be instances where that is contraindicated, for example, if there's, you know, a comorbidity, if it has severe cardiac disease, et cetera.
But then I'm really calling on my anaesthetist.Yeah, friends.I'm already very impressed with how much you know about as a surgeon.I I did think beforehand, is this a surgeon topic?This work because some surgeons might just go, no, it's nothing special.I just rock up but it's sleeping and.
Look, you know, I think that's why we have set up this brachycephalic care unit because I think we all really try our best to be up to speed and we work as a team on these patients.So everyone in the hospital kind of knows how we roll with these patients, so.
Yeah, OK, let's wake them up because this is the button that makes me more nervous when I'm doing anything to Ricky.It's the wake up.Yeah.So the wake up.So First things first, we want to internal recumbency, we want that the head slightly elevated, the neck extended and the tongue pulled rostrally.
And then the next thing.That's really important is we want a nurse I mean and this would be the situation I'm sure from most patients, but we absolutely need that nurse to be caged side and monitoring the SPO 2.And often our break is you know we have flow by oxygen for a few minutes and then we're just testing to see like are they oxygen and can they manage without the oxygen etcetera.
There's absolutely no rush for them to wake up.So we're not trying to rouse them in any way.We want their recovery to be slow and smooth.If they're starting to get anxious and the tube's still in, that's when we might give a little bolus of metatomidine.
And these boluses were giving a very low dose.And so sort of half a mic, you know, or maybe a mic per kilo.And it's delicious as well so that we can give that accurate amount.So SPO 2 monitoring and you know, one thing I'll just note on this is that we don't want a sort of a set and forget in an oxygen cage.
So brachycephalics can overheat quite quickly in an oxygen cage.So we want to be very wary of that.I'd much rather have a nurse sitting with that patient.And you know, the other thing of course is that they can become hypothermic as well.
So we're really monitoring their temperature as well during recovery and right at hand when they are recovering.You want to have easy access to not only oxygen, but suction.And then we want to have a laryngoscope and an ET tube and some Alfax and readily at hand as well.
Because obviously if it suddenly obstructs the quickest, what you have to do is you have to, to re anemotize that patient.So you need to be absolutely ready to do that.And then, you know, a bit more of the same again, in terms of really trying to reduce stress levels.
So I don't want it to be stressed, I don't want it to be painful.And ideally I don't want it to be barking at the cage door.So I want it to be nice and calm.And one of the things that we have started to allow and I, I do appreciate that, you know, we're lucky and that we do have a little bit of a, a space for this, but it's not the biggest space.
And although we're building another, another area where it, it's hopefully going to be a bit more luxurious for owners at the moment, we do allow them to come and sit cage side with their pet in recovery.Look, cannot emphasize the difference that I have noticed.
And it's not just the difference I've noticed because I, I certainly do plan on, on publishing these cases, but over the last sort of 18 months, we've been allowing owners to come and sit with them in recovery after airway surgery.We have a, a 0% mortality rate.
It really seems to make a difference.And I think it's because when we're, we're giving much less in terms of sedation, they are much, much, much less stressed.They're less likely to regurgitate.And I mean, honestly, the the complications that I have seen with airway surgery often related to you know, re obstruction or regurgitation and aspiration like those are the ones that are really.
So often related to the stress, right?I know that even from emergency where we often caring for those patients post up overnight and the ones that go South are the stress heads.They sit there stressing and panting.And then you've got the balance between, well, I've got to drug you to the eyeballs to keep you quiet or like to the point where I would sometimes send them home.
It'll be sometimes be few after hours after I actually think you're going to die with me if I don't re anesthetize you.So just go home to do that.Yeah, absolutely.And yeah.And there's that other sort of school of thought, you know, do we send airway patients home on the same day?
And I, I categorically don't.It is the risk of them obstructing overnight is extremely low.But I I keep them for that 1% that may have a problem.I don't keep them for the 99% that won't.But that's a frightening thought.Wouldn't I don't want it ever.
But you're right, that solution of saying have the brother there, it's better than home.That's the other alternative.And yeah, and the owners, really, they love it.And actually, it's an interesting thing because when we first introduced the idea, I found that the nurses were really nervous about the idea.
They really were worried about, well, what if there's a complication and the owner's there and I'll feel uncomfortable?Or what if they hear us swear or, you know, whatever it is, they were really nervous about it to the point that now there's been such a change in their attitudes that they are calling me when the dog's excavated to say, you know, when's the owner coming down?
Is the owner here yet?So, oh, wow, it's, it's really changed.It was a mindset change, but it's been one that's been really worth it.Also, I won't hesitate to have them out the back if we're performing minor procedure, you know, be it a nail trim or something like that.Not that we're doing much of that and, and specialist practice that if, if I'm feeling kind, you know, I, I really like the onus to be present fair as much as possible.
So, but certainly in recovery, that's been a real game changer for us.So you said you're in a publisher, isn't a surgeon said to me the other day there's actually publication on this owner assisted recovery.Yes, a massive reduction in complication rates and mortality.
Yeah.So there was a 2023 paper, always a little bit difficult about these retrospective papers is that often the cases that have the owners come in in recovery are later cases in terms of a time frame, if that makes sense.
So you've got a practice that doesn't have the owners in and then they have a period where the owners are in.And so the, the criticism of that paper was, well, you know, did they change other things in their protocol that made things better?So, and this time could be said for my retrospective paper, the more evidence though that we have, the more confident we're going to feel that it's a real thing and not something that is just maybe just dependent on other things that were happening in that practice.
And the other thing is that I, I'm very wary of people who, who say that they have a 0% mortality rate, you know, over a period of time, but they're not happy to sort of share that information on what they do to get that right.So I think that's really important as to if you are finding that things are going well, it's probably just as important to to publish well.
These are the things that we're doing and these are the things that we think might be contributing to a low complication like so.I logically makes so much sense and I, I and it's, it seems ridiculous that we didn't think of this sooner because you sit there all night fighting with them and then the owner comes and they come so.
It's just.Bring that is it.Oh, exactly.I mean, I certainly used to feel that nervousness as well with the owner about and you know where they're going to be a pain and yeah.But what's more of a pain?Yeah, it's more of a pain.A dog dying on your post up or an owner?
That's exactly it.That's exactly it.But high maintenance.Yeah, well, that's exactly it.We've had really good experiences with owners on the whole and they, I set them up for the fact that I, they're going to be in a hospital situation.
It can be a little bit confronting.There's other things going on.Sometimes they might be asked to move, sometimes they might be asked to be quiet or leave or whatever it is.So that is sort of clear expectations.But we we honestly haven't had any issues and they chat away to the nurses.
I mean, we're lucky enough that we have a cage side nurse for these patients so that, you know, they're dedicated to the patients.But I mean, it's interesting because, you know, often they will get the owners to do things like nebulisation and these are just for the airway cases.But often they'll have some nebulisation potentially with some adrenaline and, you know, the patients much more amenable to the owner doing it now than the nurse.
So yeah.Really, really useful.Anything we, I'm happy with that.I mean, is there anything we're missing out on?I think that's super comprehensive.For me, the main thing is just that these are the good things to think about.It's a shift to say they're not just another dog.They do stress us out.
If you do, do you, do they still stress you out despite the fact that you have such a good plan?Do you still get more nervous when you see you've got?A because I love I I love them now like they're my favorite surgery yeah, I'm.Sorry, are they your favorite patients there?Another my favorite patients, I genuinely love them.
And you know, somebody actually one of the ICU nurses over Underwood said if you don't love these patients, then don't do a lot with them because it if you're thinking, Oh my gosh, I don't want, you know, it's a friend.
She oh, it's going to be a disaster.You know, then then probably you're not the person to be treating that dog.Awesome.Well, I think they they're lucky to have you.Little problem, children.I'd love that show, that show notes.
I will make some good show notes for this for everybody listening as well with treatment guides.And again, I'm always nervous of recipes, but at least some guidelines to say, well, here's what we're using.Yeah, some guidelines and I'll send you my history template as well.That's really cool to share just so that we can, yeah, like people can get an idea of the sorts of questions that that I'm asking to assess the patient preoperatively.
Amazing.Thank you so much.Before you disappear, I wanted to tell you about my weekly newsletter.I speak to so many interesting people and learn so many new things while making the clinical podcast.
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Dr Abbie Tipler