what's up everybody my name is max feinstein and i'm an anesthesia resident at the mount sinai
hospital in new york city. in this video i'm going to be showing you all of the medications
that are included in a basic general anesthetic. if you find this video interesting or helpful i'd
really appreciate it if you liked it and subscribed to the channel. let's dive in!
the first place to start in this video is discussing what is general anesthesia,
and the most straightforward definition is: enough anesthesia that a patient is not going to move at
all when there is a painful stimulus, specifically when there's surgery going on. an anesthetic
plan will typically involve several components including analgesia, which means pain control;
amnesia, meaning a patient's not going to remember anything; areflexia, meaning a patient's not
moving at all; and unconsciousness. so all of the medications here are going to help me strike that
right balance and be able to have the patient wake up and feel comfortable once the surgery
is all done. it's really important to point out that while this may represent a sort of generic
anesthesia plan, that anesthesia is absolutely not a one-size-fits-all endeavor. i have to take into
consideration all different types of factors including what type of surgery is going on,
does the patient need to be paralyzed or not in order to optimize the surgical conditions,
how long is the surgery going on for, what sorts of fluid shifts and hemodynamic changes
do i expect during surgery, and then other factors relating to the patient such as what
sort of co-morbidities do they have, how old are they, how much do they weigh. the way that
i conceptualize an anesthesia plan is broken down into three fundamental parts. the first
is the "induction" meaning we're starting our anesthetic. the second is "maintenance"
meaning we're continuing our anesthetic. and then finally is "emergence" meaning we're
ending our anesthetic. before we get too far in this video i do need to make the obligatory
disclaimer that this video is not intended to be medical advice and it does not represent
the official views of mount sinai hospital. taking all of these different factors into consideration,
when i go to make my anesthesia plan and i'm picking drugs out of my anesthesia cart,
i feel kind of like a chef putting together the perfect combination of ingredients that is going
to be suited for the patient who's in front of me right now. for induction of anesthesia often the
first medication that i administer which i'll do as soon as we get into the operating room
and connect all my monitors is a benzodiazepine called midazolam. midazolam is a short-acting
benzodiazepine so for the patient one of the greatest benefits is that it's an anxiolytic,
meaning it's going to put them at ease right away. it also has the added benefit of being amnestic
which means for a lot of patients, their memory is going to get really fuzzy once they get midazolam,
or they might not remember anything after that. and then while the patient's still awake and i'm
getting ready to induce anesthesia, another medication that i'll administer is fentanyl.
fentanyl is in the opioid class of medication. fentanyl can be really helpful from an anesthetic
perspective because it does a number of really important things for my emergence. one is that
it's going to decrease the amount of sympathetic drive that a patient has particularly when i'm
doing what's called direct laryngoscopy. and then another major benefit that i get is that i reduce
the amount of sympathetic response from surgical stimulus that happens shortly after i start my
anesthetic. and then another important feature that we get from using opioids intraoperatively
is that it reduces the amount of other anesthetics that i need to administer in order to keep the
patient under general anesthesia. i often like to inject a medication called lidocaine
which is a local anesthetic that when inject intravascularly can reduce the amount of pain
that comes from a propofol injection. lidocaine actually has a lot of additional benefits. when
injected intravascularly as part of an anesthesia plan it can also reduce the amount of anesthetics
that i need to administer. it can also reduce post-operative pain; it can reduce post-operative
ileus; so it's something that i do like to include. next up is a medication that many of you
have heard of called propofol. propofol is very commonly used both as an induction and maintenance
medication in general anesthesia, and it can also be used pretty much by itself as the anesthetic
during monitored anesthesia care or "twilight anesthesia" as you may have heard before.
like most anesthetics it's a vasodilator which will often drop a patient's blood pressure so
this is something that we have to be very mindful of when we're inducing anesthesia and so for that
reason i also have a couple of pressors that i keep with me at all times so this is phenylephrine
and this is ephedrine. both phenylephrine and ephedrine are very helpful fast-acting
vasopressors that i can use, and typically when i do use them it's on induction of anesthesia
to prop up blood pressure a little bit in order to counteract the vasodilatory effects
mostly of propofol. once i've induced anesthesia, if my plan is to intubate the patient - which is
common but not always necessary for general anesthesia - then i need to
consider how am i going to optimize my intubating conditions. in order to get a patient relaxed,
one of the very commonly used methods that we have is to use a paralytic, and there are a lot
of different paralytics that are available but i'll show you the most commonly used.
so the first is succinylcholine. succinylcholine is in the depolarizing class of neuromuscular
blockers and will typically exert its effect for five minutes, give or take. one of the
other options that i have is a medication called rocuronium and i use this very often as well.
rocuronium is a non-depolarizing neuromuscular blocker and it has a much longer effect time than
succinylcholine. the last agent that i like to group into my induction medications is a steroid
called dexamethasone. the reason that i typically give dexamethasone is that it's an excellent
anti-emetic meaning it's going to be helpful in preventing nausea and vomiting after surgery.
maintenance of anesthesia can be accomplished in many different
ways. in front of me i have a bottle of volatile anesthetic called sevoflurane.
so in this can sevoflurane is a liquid but then it becomes vaporized and is inhaled by the patient.
as i mentioned before propofol can also be used for a maintenance of general anesthesia.
some of the other volatile gases that are commonly used include isoflurane and desflurane.
i'll typically reach for sevoflurane in a case that isn't going to be that long but if a case
is going to last a long time i do like to use isoflurane- it does have some additional cardiac
benefits and the one thing to keep in mind about isoflurane though is it can take a while for that
medication to come off, so as i'm planning for emergence i have to be mindful of which
maintenance anesthetic i'm using and how long it's going to take for that medication to wear
off. other medications that i include as part of my maintenance of anesthesia include analgesics,
so i'll commonly redose fentanyl and i'll also re-dose paralytic if the case is going
to continue on for a long time and the surgeon needs the patient to be paralyzed during surgery.
the final part of an anesthesia plan is the emergence meaning waking a patient up from general
anesthesia. the medications that are specific to emergence include thinking about reversing any
sort of paralysis that's on board. and so when it comes to reversal there are a couple of different
options that are very commonly used. the first option is a medication that's called sugammadex
sugammadex is actually one of the newest medications that's used in anesthesia
and it's specifically designed to reverse the aminosteroid paralytics,
and specifically in this case that would be rocuronium. one of the things to keep in mind
is that it can cause an allergic reaction one of the other things to keep in mind when
using sugammadex is that it can actually render hormonal birth control ineffective
for up to a week. one of the other medications that's commonly used for reverse and paralysis
is neostigmine. neostigmine is a cholinergic medication, which if you're in medical school or
you've already graduated, you know that there are a lot of cholinergic effects that can come from
a medication like neostigmine and so in order to counteract those side effects, neostigmine is very
commonly administered alongside glycopyrrolate. an important consideration to have when you're
administering neostigmine and glycopyrrolate is that the order in which you administer
those medications is really important because if you administer a large bolus of neostigmine,
it can cause really significant bradycardia which can be really problematic for your patient.
so that's why it's important when you're administering both neostigmine and glycopyrrolate
together that you administer the glycopyrrolate first so that you don't end up with dangerous
bradycardia. the other thing to keep in mind is that if you have a patient very deeply paralyzed
it's actually not safe to administer neostigmine - you need to wait until the patient is not quite
as paralyzed so that you can reliably reverse them with neostigmine. and so because of the
side effect profile, the relatively delayed onset of action, and some of the limitations around how
deep a patient can or can't be paralyzed when using neostigmine, a lot of anesthesiologists
do have a preference for sugammadex but have to consider the unique side effect profile for that
too. so ultimately making the choice between reversing with neostigmine and glycopyrrolate
versus sugammadex is going to be context dependent based on what's going on with the specific
patient. the last medication that i commonly include in my emergence plan is ondansetron.
ondansetron is an anti-emetic and it has a peak effect time of about a half an hour,
so when i'm giving this medication i try to time it so that it's approximately a half an hour
before the patient is emerged from anesthesia so they wake up feeling quite comfortable. this does
have a side effect profile as well like pretty much anything that we give, and specifically
ondansetron can be a QT prolonging medication, so if you've got a patient who has a prolonged QTc
this is probably not something that's going to be safe to administer so again you just
need to take into consideration what is going to be important for this particular patient.
well that wraps up this video, and if you found it interesting you might want to check
out another one of my videos that i'll link to right here in which i talk about how i make
sure that patients are fully unconscious during general anesthesia. if you have any feedback i'd
love to read it in the comments below. thanks very much for watching i'll see you next time