my name is Max Feinstein and I'm an anesthesia resident at the Mount Sinai
Hospital in New York City on a given day at work I frequently will administer opioids like
fentanyl to my patients who are undergoing painful surgeries which begs the question:
am I contributing to the opioid epidemic in the United States? if you find this video interesting
or helpful I'd really appreciate it if you liked it and subscribe to the channel let's dive In
this is also the perfect opportunity to point out that this video is not medical advice so if you
do have questions related to your health care you do need to talk to your own doctor. before
we get too far we should define the terms we're talking about which can sometimes be confusing.
so the word "opioid" refers to any substance that stimulates opioid receptors for example
mu receptors that are located on cells that are primarily in the central nervous system.
another term you'll hear is "opiate" which is a specific type of opioid that's a natural
derivative of the poppy seed, specifically that includes heroin morphine and codeine. and the
final term that you'll hear commonly thrown around is "narcotics." that term has several different
meanings in common parlance. one of those meanings is a substance that is mood altering
and the other definition is a substance that is specifically illicit in nature.
for simplicity and correctness in this video I'm going to stick to the term opioid because
it describes all of the medications I'll discuss that agonize the opioid receptors.
the opioid epidemic is an enormous problem in the United States as illustrated by the fact
that in the past 20 years nearly a half a million people have died in an overdose that involved an
opioid. as this graph from the CDC shows this problem has only gotten worse over time. all
of this begs the question of: if opioids are such a problem in the United States then why are they
administered by doctors during surgery? it's an even more poignant question when you consider a
patient who's under general anesthesia and is therefore unconscious and not having any
subjective experience of pain- so why do they need to receive medications that reduce pain
a big part of the answer is that even though a patient is unconscious under general anesthesia
and not having any subjective experience of pain? there still is an objective experience where the
body reacts to a painful stimulus, for example if a surgeon makes an incision with a scalpel,
even though the patient isn't aware of that, their body will still have a physiologic response that
might include tachycardia and hypertension. for a patient who's healthy and doesn't have any
cardiac pathology for example it might not be problematic to have a sympathetic response to
a painful stimulus. however for somebody who does have cardiac pathology where the heart
is very sensitive to any sort of changes and oxygen supply and demand, well a big incision
from surgery can cause a sympathetic response that leads to an increase in oxygen demand,
which the heart might not be able to provide. and in the worst case scenario, uncontrolled pain,
even if not subjectively experienced, can precipitate something like a myocardial
infarction. this is just one type of problem that could arise due to an uncontrolled sympathetic
response to a painful surgical stimulus. other examples include cerebral vascular accident that
could occur secondary to an acute increase in blood pressure. and this hypertension can
also lead to practical issues for the surgeon for example increased amount of blood in the surgical
field or even something like ruptured suture lines if a surgeon has carefully sutured together,
for example, blood vessels that if they're subjected to too much pressure could rupture.
these are some of the more catastrophic reasons that it's really important for anesthesiologist to
make sure that pain is well controlled even under general anesthesia. but something that's just as
important is making sure that once the surgery is all done and the anesthesia is discontinued,
that the patient wakes up comfortably because after all having a surgery is painful and that
pain will persist after surgery so helping the patient get their pain under control before they
wake up is an extremely important part of the anesthesiologist's job. as an aside it's worth
pointing out that opioids in and of themselves do not produce memory loss also known as amnesia
so if an anesthesiologist is formulating a plan where they want their patient to not
remember anything then other medications will need to be included for example isoflorine or
sevoflurane which are both inhaled anesthetic gases or an IV agent like propofol or midazolam
you might be wondering about alternative analgesics or pain relievers that can be
used during surgery and so one that's commonly employed is Tylenol but as you can imagine that's
not an especially strong pain reliever but it still can be used as part of an anesthetic
plan. another class of medications that's commonly used as an adjunct for analgesia are
the NSAIDs or "non-steroidal anti-inflammatory drugs" but their utility is somewhat limited
by an increased risk of bleeding, which is especially problematic during surgery, and
an increased risk of kidney damage so they need to be used judiciously. opioids like fentanyl,
remifentanyl, hydromorphone and so forth are used extremely commonly as part of an anesthetic plan
and if you'd like to see specific examples of what I've actually administered to patients
undergoing painful spine surgeries then check out this video that I've linked right here.
given how commonly opioids are administered as part of anesthesia there has been a lot of
research investigating the extent to which that contributes to the opioid epidemic.
the bulk of the research on this topic centers around a specific question which is looking at
whether or not there's a relationship between the amount of opioid that's administered
during surgery and the amount of opioid that a patient takes in the post-surgical period. a
slew of very robust research articles have been published especially in the last several years
and basically have concluded that the amount of opioid administered during an anesthetic has no
relationship with the amount of opioid that a patient takes after surgery. however one
important finding that shouldn't be overlooked is that a reduction in intraoperative opioid
administration is related to a reduction in post-operative nausea and vomiting.
over the last decade or so there's been a lot of interest in exploring whether alternative
non-opioid medications could be administered in place of opioids to control sympathetic responses
during surgery. however it's important to keep in mind that basically any medication that a patient
receives has some sort of risk associated with it, even if it's not related to opioids themselves.
this was illustrated by a recent study that compared a group of patients receiving standard
anesthetic care using an opioid versus patients who received anesthetic care where the opioid was
substituted for a different medication that can control a sympathetic response and specifically
that's a medication called dexmedetomidine. one of the side effects of dexmedetomidine
is bradycardia or decreased heart rate and during this study the group of patients who was receiving
dexmedetomidine had three instances of bradycardia that was resulted in cardiac arrest and the study
had to be stopped prematurely. there are other strategies that anesthesiologists frequently use
to decrease the amount of opioid that needs to be given during surgery and one of those
strategies is using regional anesthesia which is the injection of local anesthetic into areas
surrounding nerves that go to the surgical site. there is strong evidence that regional
anesthesia does decrease the amount of opioid that's giving during a hospital stay but it's
also worth pointing out that regional anesthesia also carries risks along with it. so basically
everything that we do has risks and there needs to be a conversation between the doctor and the
patient about the risk-benefit profile of all of the options that are available for anesthesia.
you know, at the risk of making this video to American-centric, it might be
interesting to talk with an anesthesiologist in another country and get their perspective
operator, can you connect me with the anesthesiologist outside of the United States?
Australia? like Outback Steakhouse? um yeah that's fine
ABCs of Anaesthesia: hello
Max: uh hello?
ABCs of Anaesthesia: yeah hello who is this?
Max: hey uh this is Max Feinstein I'm an anesthesia resident, who's this?
ABCs of Anaesthesia: This is Lahiru. Max um you're not on YouTube are you?
Max: yeah oh wait are are you on YouTube? are you ABCs of Anaesthesia?
ABCs of Anaesthesia: yeah how did you call me? what's going on? how'd you get my number?
Max: yeah the hospital operator called-- that's wild! well I
I really just had a question for how people do anesthesia outside
the United States. is that something you can weigh in on? are you free right now?
ABCs of Anaesthesia: yeah anesthesia in Australia-- we do everything upside
down but besides that it's pretty similar I think
Max: logically, logically. um well so I'm making a video about opioids.
you guys you guys have opioids? they they make it across the the ocean to you guys?
ABCs of Anaesthesia: yeah yeah no yeah we definitely um we definitely have opioids
and it's funny you should say that. they're a bit of a problem aren't they?
Max: Yeah uh definitely here is that a problem for you guys too?
ABCs of Anaesthesia: yeah so I mean it first became known to me because one of your one
of your mates John Oliver from New York he did a whole piece on it and some crazy statistic I
think in the U.S like 1% of people discharged with opioids will become addicted to it. that's some
really kind of horrifying statistic and Australia is not too different. like our version of the FDA,
the TGA, the therapeutic Goods Administration, they came up with this really actually really
sad fact now that in Australia there's more deaths from prescribed opioids legally prescribed opioids
than illegal opioids like heroin which is insane. that's like three deaths per day,
you know just a really sad statistic. so yeah it is definitely it is definitely a problem here.
Max: I'm curious-- I know that it is probably difficult to quantify this but if you were
providing anesthesia for again a routine appendectomy for a 70kg, 30 year old patient,
roughly how much and what opioid would you administer to that patient during surgery?
ABCs of Anaesthesia: for the induction most people would give alfentanyl or fentanyl and
say most people would give in the range of you know 1000-2000 micrograms of alfental or they'd
give you know 100 to 200 micrograms of fentanyl and that's just for the intubation. but there's
a big trend towards giving fentanyl, like each anaesthetist will probably just take out a 500
microgram vial of fentanyl at the start of the case and then you know give 100-200 at the start
and then titrate 50 micrograms per every 15 to half an hour for the rest of the case so
you know if the case went for an hour you'd get maybe another 100 to 200 micrograms but
if it did go longer, if it was a complicated lap chole [laparoscopic cholecystectomy] or
complicated procedure you might end up you know giving the full 500.
Max: yeah that's fascinating what you're
describing is basically exactly the same type of dosing regimen that I would use
ABCs of Anaesthesia: hey do you use much remifentanyl?
Max: we use a lot of remifentanyl. we have a very robust ENT department at my hospital
in particular and find that the pharmacokinetics of remifentanyl are very favorable for surgeries
that are very stimulating intraoperatively and then have very little post-operative pain, so
having a medication like remifentanyl that's fast acting and quick to be metabolized is an excellent
option for those types of cases so yes we do use remifentanyl quite frequently in our hospital.
ABCs of Anaesthesia: yeah nice we find that yeah I totally agree like I I pretty much use
it routinely for the ents and the turbinectomies and you know you get less blood loss better
surgical View and all that kind of stuff. but then if we ever see the pain guys- like we've
got a bunch of really great pain doctors in our in our team in anesthesia in Melbourne, and if
they ever see you running remifentanyl during other cases like you know big laparotomy cases
they'll probably just be like why are you doing that? you know they're always worried about the--
Both together: Hyperalgesia!
ABCs of Anaesthesia: yeah you know the effects of remifentantyl
Max: it cost something that you guys think about it all? and at the risk of making this video extra
controversial now because I have gotten some very let's just say spicy comments on a video that I
made about providing anesthesia for spine surgery in which remifentanyl was prominently featured,
and there was a corresponding relatively higher cost associated with that medication, is that
something that comes into consideration at all when you're coming up with your anesthesia plan?
yeah but fortunately the opioids pale in comparison to the other costs of our department
so I think sugammadex is pretty expensive for us overall. metaraminol is a huge cost,
and maybe propofol you know just the commonness of using, it's pretty much the only game in town
for inductions for us. but yeah so we don't think about it too much and I've got to say
most people just aren't using remifentanyl with any kind of frequency that's probably gonna gonna
stir that problem up at all, so yeah cost is definitely a big thing but not for remifentanyl.
Max: interesting, well could be a topic for a future video of ours!
ABCs of Anaesthesia: future video yeah that's right
Max: well I really appreciate your time thanks for taking this collect
call because I I wouldn't like to charge this to my hospital since I'm calling from the landline,
so it's very very generous of you with your with your time
ABCs of Anaesthesia: hey just pay forward, no problems at all
Max: well it's great to talk with you and I'll be sure to check out
your channel and point my viewers towards your channel as well because you produce
excellent content that is absolutely worth watching
ABCs of Anaesthesia: uh thanks so much and likewise you too, and you know I'm gonna
have to give you a call sometime during one of my videos and get your perspective,
so yeah look forward to the next one, see you Max have a good one
Max: all right you to
well that was interesting and if you enjoyed this video you might want to
check out this video where I narrate all of the commonly used medications
as part of a general anesthetic. thanks very much for watching see you next time