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Right. Um We've had some technical issues but can people confirm that they can hear what I'm saying? And I'm now gonna try and share my powerpoint slides. Mhm. I can't find my um slides, get back into the winter and then you can just get onto your slides. Say it again. What's that, that one? Yeah, I wanted to share my screen and I can only share. Yeah. Yeah. OK. Ok. So tell me if people can see the slides now. No. OK. Yeah, I can't see any of the questions as this is happening. So, um if someone keeps an eye on the chat and lets me know, um I also can't see how many people are here but welcome to anyone who has managed to log in and get started, sorry that we are all a bit delayed. Um There's a code for mentee, which I will use a couple of times throughout, but I can come back to the start slide um during the presentation at the time of the questions. Um starting off with a disclaimer. I am an F two not an anesthetist. So I will do my best to describe how an anesthetist, um, sort of what they sort of do and perioperative care from a hospital setting. This is the stuff that we will vaguely cover. Not necessarily in completely this order. So, starting off with a mental question, what does an anesthetist do? I'll just go back to this first slide so people can see the QR code and the mentee. All right. Cool. Um, I need to try and now work out how to open mental on my laptop. Mhm OK. Cool. Is this working that? Yeah. Right. Does it only let you fill in one question? OK. Mhm. Mm Yeah. OK. This is what we're working with so far. Can people si don't know if people can see that on the screen? Fine. OK. Um Yeah, so I'm not gonna um labor the mental point a week having Scott's issue of slides not moving now. So as that's moving on from the we had sort of manages an airway, puts people to sleep. Um A lot of what people think the anesthetist does is very much around just operating theaters. Um So obviously the obvious general anesthetics, local anesthetics, getting people ready for um operation, understanding past medical history and how all of those different conditions that patients have work to like sort of interact with each other and make an anesthetic just that little bit more complicated. They can put the brakes on for very enthusiastic surgeons and say no, we're not doing this today or we're not doing this at all and can stop that from stop operations from happening. If they're not in patients best interests from an anesthetic perspective, they are communicators. If you think that there's some operations which happen when the patient is awake, but they are behind a curtain, it's the anesthetist who communicates with them, then um they sort of help make complicated operations happen. They are in charge of the physiology, whilst the surgeons are in charge of the operation itself, they help postoperatively, they help massively with pain management. And there's a massive role in obstetrics. Um outside of the operating room, there's emergency care. Someone said on mental, um sort of looking after unwell patients, sort of managing an airway. Um If you think of the cardiac arrest team, anesthetist is always heavily involved there. They work on it and there's a lot of jobs, um a lot of role in pain clinic. So let's use Robin as a example patient who is completely made up and this picture is not a real person. It's made by A II, don't know who he is meant to be. Um, but he's 80 he's had his left total knee replacement and would now like a right total knee replacement. He's a type two diabetic, his BP could be better controlled and he has got CKD. Um, he's got af um all of his joint problems are driven by osteoarthritis, which is quite common in 8080 year old man, he's got a slight iron deficiency anemia. Um He's a bit anxious and has never had that conversation about respect. Um and escalation of care and treatment. Um got his drug history on the right. So nothing too exciting but quite a few different things that can interact with each other. And if you think about him from a anesthetic operation, POSTOP perspective, a few things that we probably need to have a little think about. He's got a really good quality of life. He does care for his wife who's got dementia. Um But actually home setups. All right, in their bungalow and family visit a couple, visiting a couple of times a week and he's fairly independent um from himself. Um He's probably a little bit overweight. He smokes three cigarettes a day and drinks half a bottle of wine at night. So he's a fairly standard patient of what you see that walks in the door in a GP surgery or in a clinic or in A&E. So what do we need to consider before booking this chap in for his knee replacement? Because it is not quite so simple as he wants it. So we'll operate on him tomorrow. So we follow um nice guidelines. Um As with most things, there is a guideline, um They sort of guide us about what we need to find out about a patient before. Um and we um come up with a sensible plan. The tests are dependent on the patient and not the procedure. So, before, um, any patient that's going to be, um, operated on, we need to know what the medications are, the smoking history, alcohol history. Quite unlikely in an 80 year old but not unheard of for illicit drug use. We want to know about their, um, personal family, history of their previous operations. We know he's had a hip, he's had a knee replacement before, so he's had an anesthetic before. Was there anything complicated there or was it fairly straightforward? Is he allergic to anything pretty much every patient is gonna need an ECG depending on the sort of age and their comorbidities and echo um, bloods and obviously not with this chap. But pregnancy test, we need to know if the patient is pregnant before considering any procedure we need to work out. Is this really what's right for him? Does he really need surgery at this point? Have we tried all other things because we want to avoid surgery if possible? And does he really know what he's getting into? Um, he needs to make sure that he's got a consent form signed that he fully understands and makes sure it's informed consent. Uh, he knows what's going on. He's a carer for his wife, that's not insignificant. So, how long is he gonna be in hospital? Is he gonna need to be inpatient rehab or is it likely that he's gonna be able to rehab at home? And I know home's a bungalow and home is well set up. But is that gonna be a safe discharge location for him? And will he still be able to look after his wife? Um, and if not, what are we gonna do about her? Um, the sort of more, um, laid out, straightforward part that we can sort of, has got a lot of research into is how risky of an anesthetic. Will this be if we go ahead with it? So this is not done randomly, the American Society of Anesthesiologists as they call them, there has a physical classification system which a few of you will probably have heard of, which is the A SA grade system. Um I would say most young fit patients are grade one or two. Not so much in the way of past medical history or comorbidity. Um Things get a little bit more complicated around the 34, around the grade five. That's when you don't really have much of an option, you're gonna have to do this operation if you want them to have any chance of survival. And grade six is brain dead patients for um organ donation. So not something we hear about all the time. This just sort of lays it out with a bit more example. So this is how most people will fall into grade one or two. So healthy nonsmoker, not too much alcohol intake, grade one. If you think that then a current smoker or drink a little bit more alcohol than they should socially or they're obese or they've got well controlled chronic conditions, you put them as a grade two and then grade three is probably the most common, I would say. Um, they've got a bit of a functional limitation due to their past medical history, one or two, severe medical conditions. Um, if you think hypertension COPD and diabetes fall into that category, if they're not really well controlled, um, that is how most people end up as a, as a grade three. So back to Robin, if we look at his past medical history, things that are gonna factor into what grade he's in. And surprisingly, all of the sort of things that I've highlighted in bold add up together and will probably say that he is in a sa grade three. So it's not ideal, not perfect. Um, if we're gonna operate on him, we might want to have a little think about what we can do first. So let's give him the best chance possible. He's not massively overweight, but we could lose, could recommend that he loses a little bit of weight from a musculoskeletal pains, perspective, that weight might help. He's a type two diabetic, not on any medications at the moment, but losing a bit of weight will help there. It makes for a safer general anesthetic and just improving his physiological baseline and his functional baseline. It will help with his recovery postoperatively, like we said, his BP was a little bit high. We could manage that and that will help with protecting his kidneys. Um, start something for the diabetes. He's only smoking three a day, he may be able to stop that. Um, smoking in itself has a massive impact on bone healing for starters. But also if you think about the impact of that on his lungs, um iron replacement, that's something that's simple, fairly low risk and fairly easy. We can do that whilst in the run up to waiting for this operation and somebody should be having that conversation about respect just to make sure that we have a plan and the thought has been brought up to make sure we're doing what we think is best for him, but also what he thinks is best for him and what he wants just before an operation, we can think about whether he needs MRSA eradication. He'll be made no by mouth to make for a safer anesthetic. Um He can make a plan for his wife, make a plan with his blood thick thinners and make sure that we have marked a surgical site and are operating on the right limb. So if this all happens perfectly and this is all in an ideal world, we might be able to move Robin to a grade two, which is a safer anesthetic. So it all goes great. He has his total knee replacement under a general anesthetic. He has a femoral nerve block to help manage his POSTOP pain, minimizing the need for oral analgesia and everything goes well, happy customer. So how do we choose what type of anesthetic to use for each different patient? So as I mentioned, Robin had a general anesthetic and a peripheral nerve block. So there is a bit of a rule of threes. There are three main types of anesthetic that we can choose from. There's the generals who put people properly to sleep, there's regional where they are awake, but we sort of numb the sort of lower half or a specific limb or there's the local anesthetic, which is for sort of much smaller things. Um um with sort of injectable local anesthetic. At the end of the day, there is no hard and fast rule. As long as your patient is not moving and not in pain, they have to be able to tolerate the procedure. Um And it is up to a combination of the anesthetist and the surgeon and you have to make sure that the anesthetic is appropriate for not just plan a but for any of the sort of potential complications that may um go on. So a small hernia, theoretically, if you're really ambitious, you could do it under local. Um But as you consent, someone for a small hernia repair, you say, oh, well, we might have to convert to an open laparotomy. It's not ideal if you need to convert to an open laparotomy because you've perforated the bowel and you've got local anesthetics. So you kind of need to make sure you're planning ahead and minimizing sort of risk of a last minute decision. So, continuing from this rule of threes, there's general regional local which we've discussed and then going deeper into the general anesthetic side of things. There are three stages. So induction which is get the patient to sleep maintenance, which is keep the patient asleep and emergence, which is let them wake up again at the end. Um And then the final three final part of the um rule of threes is the three components. So this one is a little bit looser than the others. Um But as a, as a general rule for a general anesthetic, you've got hypnosis, analgesia and immobility, immobility being slightly in brackets because you don't always need to properly paralyze the patient with something like Rocuronium. Um It can sort of help make an easier intubation or easier surgical access, but you can be intubated without being paralyzed as long as you are sedated enough and have enough pain relief. Um That's quite dependent on the procedure. Um and um sort of how much control the surgeon and the anesthetist need through out. So induction quite often, this is what you'll see. You'll see the niece just turning up with a massive tray full of different colored drugs or with different colored labels and that's how one of the ways that we can induce a patient, we can use injected drugs. So IV drugs or inhaled drugs. Um So the IV drugs are things that you may have heard of like propofol ketamine, etomidate. They are drugs that are given IV, they are metabolized by the liver and they are excreted by the kidneys. They're lypophilic. So they go from the bloodstream to uh lypophilic tissues. So that's how they end up in the brain and spinal cord and work as a general anesthetic um induction agent gasses, things like sever fluorane, desflurane and nitrous oxide. They are a bit quite flexible in that you can give them via a normal face mask or you can give them via a endotracheal tube. Um So these are drugs such um I've done the examples already. Sorry. Um These are really good in terms of induction for kids because it means that you can get a patient nicely to sleep without having to put in the cannula. And the cannula can go in once they're um still and relaxed and not um sort of distressed by a thought of a cannula. Um TIVA, this is total intravenous anesthetic and it is something that we are very much moving towards because one of the main negatives of anesthetic gasses is although they are nice and titratable and work really well. Um They are absolutely hideous for the environment, nitrous oxide on its own accounts for 2% of all NHS emissions. Um And desflurane is 2500 times more potent than carbon dioxide as a greenhouse gas. The reason that we have them is that they, the general anesthetic as a procedure was invented before the Cannula. So there was a little bit more limited options. So you give the induction agent, this gets them nicely sort of unconscious and um ready to go if you're using a paralytic. This is when you would give your paralytic. Um And that's when you would put the tube in, once the tube is in, you make sure it's nicely in the right position. Um And you fix it in place. Um The way that you can confirm that it's in the right position, it's simple things like making sure that the chest wall is moving. Um sort of looser things such as seeing misting in the tube, but most specifically, we look for five waveforms on the capnography tracing. So that just shows that we've got five good breaths of air in and out of the lungs. So that's induction. The next part is maintenance. Um You can use some of the same drugs for induction as you can use for maintenance. And the goal here is to make sure that they stay pain free and they stay unconscious um using as little medication as possible throughout the procedure. Um In terms of unconsciousness, we can again use gas or IV. Um And from analgesia, it's just worth knowing that you can still be in pain whilst being unconscious. Um which is why some of the um the monitoring comes in handy. Um Because if someone is in pain, they may become tachycardic and hypertensive. At which point, they sort of can do a little bit of changing of your anesthetic drugs and make sure that pain relief is topped up. You can do pain relief by sort of simple things. So you give paracetamol, you give an NSAID, you can do a bit of local anesthetic and give breakthrough opioids or you can do sort of a bolus or continuous infusion of an opioid or original anesthetic, like we sort of mentioned earlier and I'll go into a little bit more detail later then dependent on the surgery, dependent on the surgeon and dependent on the anesthetist. So just a little note on anesthetic drugs and BP. Specifically, most patients who are going in for a big surgery are going to obviously be attached to all sorts of different monitoring. Lots of them are gonna need an arterial line which constantly measures BP and some of them are going to need a central line which allows us to give drugs to the large central veins. Um This is because of the massive effect of majority of the anesthetic drugs and BP. Um So this is our, um where are we um sort of the equation where we used to work out our BP and anything that's circled can be reduced by majority of the different anesthetic agents. I'm not going to go into massive details on this because it's pretty much an entire lecture worth of um like sort of um science behind that. Um But it's just to show that there's so many different elements that are impacted by your anesthetic drugs. And therefore, a really, really, really common thing is to need vasopressor and inotropes just to stop this BP from becoming a problem if you're having to keep somebody um under general or sedated for a long time. So, moving on to this is used on its own or alongside a general anesthetic um that are local and regional anesthetics. So this is back to this slide. Um the spinal epidural peripheral nerve blocks and local anesthetic. So all of these different techniques use similar drugs, um usually an a local anesthetic, an opioid or a combination of the two with or without adrenaline and they use similar drugs but in different concentrations and different anatomical locations. Um So they're really, really good at being used. It's basically a way of avoiding having to do a general anesthetic, which in itself is quite an undertaking for a patient. And the pain relief aspect of things can last much longer than the operation itself. Um and they can be used as a pain relief without even needing an operation anyway. So the reason um adrenaline is often used um is adrenaline causes local vasoconstriction. Um So reduces blood flow to the area. Um And therefore that sort of slows down um how quickly the drugs are absorbed and that can prolong how long they are active for. Um So it means we can give a longer, a higher dose which can last a lot longer without coming toxic. And it's just worth noting that you can't give that in digits or in someone having an anesthetic involving their penis because it can cause tissue necrosis. Yeah. Um So yeah, that's sort of the basics around that. Um So a spinal sometimes called a subarachnoid block. Um This goes back to your spinal cord anatomy. You're giving your medication here into the same place as your CSF. So into the subarachnoid space, you have to go through the juror and inject, inject the drug there. You get a pretty sudden onset dense anesthesia. So it's sensory and motor. Um and because you're going into the CSF, you're going right, right near the spinal cord. So it's very similar to a lumbar puncture. You need to make sure that you go below the termination of the spinal cord to make sure that you're not going to cause any damage there. If you accidentally sort of touch things with the needle, they are a single shot medication. So it's needle goes in and needle comes out. Um It lasts a good couple of hours, 2 to 3 hours. So they're really good for any operation that is below the abdomen. This does include C section and it's really commonly used in joint replacements. Um I didn't quite understand when I first heard about these, how you can have something that's in a loose column of liquid that only affects your lower limbs and doesn't sort of spread around. Um, and cause higher up uh sensory and motor loss. And it's basically the same as this. It's because we use dextrose and make the drugs hyperbaric. So they are much more dense than CSF and they sink to the bottom. It's just very much means we need to make sure there's a good tilt on the table. Um And if your patient does have a funny turn after giving the subarachnoid um injection, don't lie them completely flat and put their legs in the air because you'll make the problem so much worse. Um So we help, we use gravity to help make sure the drug stays in the right place. So the epidural is one of the other options. Um So in the picture there, the very bottom needle is the, the spinal, which is right by the um end of the, the spinal cord that we just discussed. The epidural is in that as it sounds epidural space. So you remain outside of the jura, this means that you're not going so near the spinal cord and you can therefore go a bit higher up and you can be it can be used for things like thoracic surgery. Um, and this is the common one that we use in labor because we're not going so close to the spinal cord. It's, um, can, it can give a pain relief without a motor loss. Um, and the way that we measure how much effect it's having is we use cold spray. Um, so because it can be quite hard to manage, quite hard to sort of work out how much of an effect it's having and how much benefit it's having without inflicting pain on our patients going up their legs. So use the cold spray, relying on the spinal tracts to make sure that we've got a good block as it's described. Um This one is quite flexible. You can either do a single injection or you can have an epidural catheter. Um, catheters are quite good in that they can um be topped up as needed. They can be used for a continuous infusion and they can be really, really topped up and used as an anesthetic if for example, a laboring lady needs to have ac section. Um So they can be really flexible. Um like all of these um different types of an um anesthetic, they cause hypotension, bradycardia because we're sort of fiddling around with the CNS and just need to be aware of it and keep an eye on people's BP when doing it. But we do often need vasopressor alongside this. This is what the epidural needle and cannula looks like. It's this sort of longer bigger stripy one in comparison to. So left is epidural and right is spinal. So it's a lot bigger of a needle than the spinal one. just for reference. And then finally, the regional nerve blocks, these ones are really clever, they act on a single peripheral nerve. So it gives site specific anesthesia. So really good for shoulder surgery, for example. Um or if somebody's had a broken kn and they're waiting for a operation, you can put in a fascial I block and it gives good pain relief without having to give her frail old lady, lots of opioids which can cause all sorts of problems of their own. Um They are often used alongside a general anesthetic. So you'll see someone come out of a laparotomy with rectus sheaths, um which allows you to give local anesthetic topped up just around the site of the procedure. Um And minimizing again, it's mostly trying to minimize opiate pain relief postoperatively. So I'm gonna try to go on to ment again. Does anybody know any contraindications for any of these different types of pain relief kind of bearing in mind? Sort of similarities to um a lumbar puncture for a bit of a hint five. Is that question working? Ok. So I've got allergy to local anesthetic, raised intracranial pressure. Um C NS infection trauma. What's that one? Say hypotension? Yeah, I'll leave it for a couple of seconds. See if anyone any other responses. OK. So pretty good. Mm Why is it not working? So the main contraindications in bold, flat out refusal from our patient localized infection which was already mentioned on mental and allergy to local anesthetic. Good inability to cooperate is quite a key one. And you have to bear in mind that you can do a hip replacement under a sort of epidural or spinal anesthetic. But you have to have a patient who is going to be able to lie on a table and remain fairly calm whilst there's a room full of orthopedic surgeons, drilling and soaring and chatting and that's quite traumatic and they need to be able to cooperate and tolerate that without getting really agitated or moving. Um Abnormal anatomy is pretty self explanatory. You're going into pretty specific anatomical locations. You need to make sure you know exactly what you're aiming for. Um Anything that's gonna make you bleed more than you would like is a problem, neurological disease and hemodynamic instability. So, yeah, that was also mentioned on mental hypotension. Um and some of the complications are, it may not work. Um You might do a bit of nerve damage. You wouldn't say people had their epidural during childbirth and still have a tingly toe. Um It's a bit of a risk benefit there um can cause hemodynamic instability. You can get a headache when you puncture the dura similar to a lumbar puncture, um, get a nasty headache. Any, anything like this can introduce an infection. Um, and yeah, maybe think about a, a catheter and might go into retention. So, we've got Robin, he's the same patient. We haven't done any of his fine tuning pre op. But if, if you think about him and he's this time having an emergency laparotomy, he's got a perforated large bowel and he is septic. So, not in a good way at all. So he's still type two diabetes, hypertension, chronic kidney disease. Um, he's on all of these different medications. He's still smoking, he's still a bit overweight. Um, he's still not got a respect form and he's just had his lunch. Um, he's vomiting, he's a bit delirious. He's not doing well at all. Probably at this point would say he's in ASA grade five. He's not going to do well, if we can't get this under control and to get this under control, he needs this operation. So normally a traditional intubation is planned calm. It's, everybody knows it's coming. The patients been know by mouth the night before. It's nice and low risk and we have lots of options. We don't always have to use an endotrachial tube like this. Um, you can consider using something like an eye gel. You have to use the, um, tube if there's sort of risk of regurgitation or airway soiling. Um, or if you think that it's going to be somebody that's difficult to ventilate. They give you a little bit more control, but you can consider using an L like an eye gel. Um In Robin's case, he's going to probably need what we call RSI, which is rapid sequence intubation or induction. This is our emergency risk reduction intubation. The way we'd like would do it is you pre oxygenate for three minutes. So hold an oxygen mask with um over their mouth for three minutes. Um given the induction agent and a neuromuscular blocker. So there is no option here. You've got to paralyze the patient and you give cricoid pressure before inserting the endotracheal tube. It's because our cricoid cartilage is a nice ring and it is a sort of firm ring around the. And if you press on it from the outside of the neck, you can put a little bit of a clamp on the esophagus, um which is a nice way of reducing the risk of a patient that's got a full stomach aspirating and um that going into their lungs. But the goal here is speed. Um you need to get the tube in, in less than a minute. These are risky um intubations that we like to avoid patients who are delirious and agitated and fighting you and batting away the oxygen that you're trying to preoxygenate with and not cooperating. There's delayed sequence intubation, which is basically exactly the same. But you start with the ketamine, you get the nice and associated and you then do an RSI once they're associated. So we might be thinking about it or HD U POSTOP for somebody like Robin who's having his laparotomy. What can it? And HD U provide POSTOP that a normal ward maybe can't let me get mental moving on. Mhm. Got organ support. 1 to 1 nursing intensive rehab. Mhm. Ok. So that's a few of the positive things that I to you can provide. I would agree. So organ support, respiratory cardiovascular renal, you've got the nice high close monitoring and high nursing ratios. So people can be, you can't really miss things when there's 1 to 1 nursing. Um and because of this, you can be really nice and liberal with analgesia. You see people kicking up a fuss about giving IV morphine on the wards when there's a one nurse looking after 12 patients. But if it's 1 to 1 and they can properly watch that they're not becoming a toxic, it's a lot safer. Um And key part would be early recognition of any deterioration, but in terms of negatives, we can be sort of over dramatic and overtreating, sort of giving a vasopressor when actually this was a normal fluctuation in BP that wouldn't have needed vasopressors if it had been on the ward. Um the more things we do, the more things we get involved with, the longer they stay and that's a massive risk of delirium, sort of reduce reduced mobility from on the ward. It's a lot easier to stay in bed and have things brought to you. If there's 1 to 1 nursing, I know there's lots of excellent therapies on it to, but it can be easier to have reduced mobility. Um And they might end up as an emergency admission to itu from a complication from an operation that was always going to be unsurvivable. And actually there's no benefit of having gone to itu for that. And another massive factor is cost. So it's three times more expensive to have someone in an it, but this was back in 2017 than it is on a normal ward. So it's not something to sort of choose lightly. It's much better to have a planned admission than an unplanned admission. Mortality is just so much higher in an unplanned admission. But that being said, it's really difficult to predict, um, who's going to need POSTOP care. So you'll see patients going to a HD for, for, um, bed and breakfast. So they'll turn up from the procedure, stay the night and be discharged in the morning, having not needed any support at all. Um, and potentially that could be avoided. It's usually abdominal or orthopedic surgery that patients end up having an emergency admission with. And it's nearly always for vasopressors. These are common post anesthetic complications, nothing too dramatic. The ones involved may land you a bed and itu um, things get really severe, but these are things that are quite common and not too concerning they problematic complication. Number one is malignant hyperthermia, which we don't hear about as Junior juniors because it happens in theater and it is an emergency. Um It's an, it's usually linked to autosomal dominant condition. Um Genetic mutation affects two in 100,000 people per year. Basically, your cells fill to the brim with calcium causing prolonged muscle contraction, muscle breakdown. Um and it's usually triggered by the volatile gas anesthetic. So the flu in isoflurane, um you get mass to spasm, massive rigidity, massive rise in end tidal CO2 massive rise in body temperature. And you get renal failure and arrhythmias from basically muscle breakdown, rhabdomyolysis, hyperkalemia. It's an anesthetic emergency. You switched to total IV anesthetic, you actively call them, you can give Dantrolene which reduces in calcium and you get them to itu for close marching. Another one, local anesthetic toxicity. This one is um also a life threatening emergency. Um Generally, it's happens when someone is giving local anesthetic and they accidentally inject it into and vein or an artery. Um That's when it normally happens. Um It can happen in people with chronic liver, cardiac or renal disease, which can sort of reduce clearance um from the body and it then can accumulate but it's usually from accidentally giving it um intravenously. Um Any and local anesthetic has a maximum safe dose. Those safe doses are higher if you give it mixed with adrenaline. This is um quite dramatic sort of presentation of ultimate status seizures, comas, cardiac arrests, arrhythmias. Um You can really tell that something is wrong when this happens. And the key to management is lipid emulsion therapy. And anything, any seizure management. If they present with cardiac arrest, you give the lipid emulsion therapy and have to do prolonged resuscitation to give it a chance to work whilst the um the local anesthetic clears from the system. But, yeah, unavoidable problem. Really. So that's pretty much it. The key to sort of, I think the main thing that we've covered is to make sure that everything is planned. So planned procedures, planned anesthetic, you have sort of, you know exactly what you're working with and if they're gonna need I to make sure it's planned, um, this helps improve outcomes. There's the rule of threes um, for different types of anesthetic in different stages. And basically the goal is to try and do as little as possible because there are so many risks associated with all of the drugs and procedures that are involved with giving an anesthetic that we try and avoid if possible. So, any questions? Mhm. No questions. Cool. Right. I don't have to end this or something.