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 different types of
operating rooms and explaining how the equipment used for different types of surgery can have real
implications for the anesthetic management of patients. 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.
the reason why i wanted to make this video is to highlight what an anesthesiologist actually has to
know about the special types of equipment that's in a room depending on what kind of surgery is
going on. back when i was a medical student before i really knew very much about anesthesiology
i thought the only thing that anesthesiologists really had to know about was endotracheal tubes
and how to put somebody to sleep for surgery. as a third year medical student when i became
more interested in anesthesiology i spent more time talking with anesthesia attendings and
residents to gain an understanding of what exactly they needed to know about and so i was really
fascinated to learn that not only do they have to know about all the anesthetic drugs and all the
sorts of procedures that anesthesiologists do, but also pretty much every medical condition and how
there's an interaction between the anesthetics, the medical condition, the type of surgery that's
going on, and then as i've been in residency i've learned about how the different types of equipment
in the operating room have implications for how i manage a patient. so that's what i wanted to share
in this video. one very unique operating room is for neurosurgery, and in neurosurgical operating
rooms there are a couple pieces of equipment that we don't typically find in other types of ORs.
so one of those is an actual CT scanner which the neurosurgeons use to evaluate what's going
on with the patient at certain intervals during surgery. but one of the big implications for me
is that it makes it a little bit more difficult to route all of my equipment so that's going to
be my airway equipment, my IV equipment and monitoring equipment to get to the patient.
so in a lot of cases this means that i need to go through or around the CT scanner. the reason why
this can be such a big deal is because in the event of an emergency if i need to be able to
access the patient's airway or need to be able to access monitoring equipment or IV equipment it can
be a little bit more challenging if i have this big donut that's in between the patient and me.
along those lines it's pretty common during neurosurgery to actually rotate the operating
table 180 degrees so that the patient's head is away from me. this makes it a lot easier for the
surgeons to be able to access the operative site but this can make it a lot more challenging for
me if i need to do airway management during a surgery. one of the other unique factors
about being in a neurosurgical operating room is that there's often a neural monitor there,
and a neural monitor is somebody who's received specialized training - usually a master's degree
or sometimes a phd - in order to provide feedback about neural function of a patient during
a surgery in real time. neural monitoring is really important for the neurosurgeon as they're
operating in really sensitive areas that might have to do with motor skills or visual abilities
or other types of sensory abilities. and so the implication for the anesthesia provider
is that the drugs that we use might affect the neural monitoring, and so that might mean that we
have to avoid paralytics because a paralytic would stop a neural monitor from being able to pick up
changes in motor abilities of a patient real time during surgery. keeping the importance of neural
monitoring in mind, as the anesthesiologist i have to choose medications that don't actually
paralyze the patient but that do keep them from moving at all during their surgery, so they're not
technically paralytics that i'm using during most neurosurgeries but the medications that i do use
keep people from moving anyways, and this is really important because as you can imagine the
neurosurgeon needs to make sure that the patient is not moving at all because they're operating
on such a sensitive and small area, usually in the brain or sometimes in the spinal cord. often
for neurosurgery the choice of medication that i use to achieve this is a very short acting, very
potent opioid called remifentanyl. there are lots of other options as well but in my short amount of
experience this is the most common medication that i use instead of one of the more commonly used
paralytics, for example rocuronium which i use for a lot of different types of surgeries. these are
just a few examples of the special considerations that anesthesiologists have to have while
providing anesthesia for neurosurgery. but in fact it's such a specialized field that there's its own
fellowship for anesthesia for neurosurgery that one can do after completing anesthesia residency,
that's usually a one year long fellowship and we have one here at mount sinai. another
type of surgery that has some really important implications for the anesthesiologist is robotic
surgery. so robotic surgery has become popular over the last couple decades and has been really
helpful for gynecologic surgery, genito-urinary surgery, general surgery like hernia repairs, and
a number of other different types of surgeries. one thing i should point out is that robotic
surgery doesn't mean that there's an autonomous AI robot that's performing surgery without anybody
helping out. instead, the robot is actually this big piece of equipment that can be loaded
up with different types of surgical instruments that go through little incisions that are made,
usually in patient's abdomen, and then the surgeon sits nearby at a computer terminal
and there the surgeon has these special controls to use this equipment to do operations,
and this allows the surgeon to use unique technical abilities that someone couldn't do by
hand ordinarily. one of the unique considerations for me as the anesthesiologist during a robotic
surgery is that a patient has to be completely paralyzed because any sort of movement
while all the surgical equipment is attached to the patient could lead to problems, and it
could also make it a lot more difficult for the surgeon to continue actually doing the procedure.
as i mentioned, anesthesiologists have access to a lot of different medications that can provide
paralysis for patients and so it's important for me to have an understanding of which medications
are appropriate for what types of patients. there are some paralytics that require kidney
function in order to be metabolized and other paralytics that don't require kidney function,
so any sort of medical history that the patient has is going to be important for me as i pick out
what type of paralytic i want to use. and then one of the special pieces of equipment that i use on
my side of the drapes is a nerve stimulator which allows me to see how paralyzed or not
a patient is. and it's really not an on/off binary type of thing, but paralysis is more
of a continuum where a patient can be not paralyzed at all, completely paralyzed,
or somewhere in between where there's some muscle function but not that much so that a patient is
weak but not completely paralyzed. i also just want to point out here that any time we're using
any amount of paralytic for a patient, they are under general anesthesia. they are not aware of
anything and they are completely unconscious, not making new memories. another important implication
for me during robotic surgery is that the surgeon actually inflates the abdomen, mostly with co2,
sometimes other different types of gases are used but by and large it's co2. the reason why
surgeons do that is so they can have more room in their operative environment and actually this
is done during laparoscopic surgery as well, not just robotic surgery but anytime the surgeon is
insufflating the abdomen, meaning filling it up with gas, that has really important implications
for respiratory mechanics which affect me and the ventilator that i'm using. so that can lead to
higher airway pressures. it also leads to less lung movement which is usually not a problem but
these are things that i have to keep in mind because i can actually see on my anesthesia
equipment what airway pressures are, and i need to make sure that they stay in a safe range so
if i'm providing anesthesia for robotic surgery or laparoscopic surgery, i need to be aware of
the effects that abdominal insufflation is going to have on how i'm ventilating a patient. it's
also worth pointing out that insufflation of the abdomen can have important effects on circulation
of a patient and have cardiovascular effects that are important for me to keep an eye on as well.
as long as i'm talking about robotic surgery, it would be a huge oversight for me to omit how
comfortable the chairs are that come with the robotics equipment! so if there's an extra chair
that's sitting around, you better believe i take it over to my side of the drapes and use that. one
surgical factor that anesthesiologists have to be really knowledgeable about is patient positioning,
and it might sound like a trivial thing but improper positioning during surgery can lead to
nerve damage, it can lead to vision damage, and also surgeons care a lot about positioning because
that affects their operative environment - it can make it either a lot easier a lot more difficult
to do their surgeries. as a resident who's early on in my training, i'd have to say one of the more
intimidating types of positioning for a patient to be in is for spine surgery that requires that a
patient is prone, or on their stomach essentially, and the reason why this is such a big deal to me
is because i can't actually access the patient's airway, or at least not very easily,
so if there were any type of emergency that happened during the surgery that required that i
accessed the airway, i need to have already planned out how i would deal with those problems
as they came up. for these types of surgeries that require patients to be prone, we actually
induce general anesthesia with them supine and intubate supine as well,
and then flip the patient over onto their stomach into the prone position after we've induced and
intubated. for me that means that i have to put extra consideration into making sure that
i've secured the endotracheal tube so that it definitely does not go anywhere during surgery.
another really unique type of surgery to provide anesthesia for is a c-section,
and in addition to its own unique surgical considerations, one of the environmental
factors that's so unique about c-sections is that not only do you have a patient who's awake for the
most part - although occasionally we do general anesthesia for c-sections - but you also have the
patient's partner who's sitting right there next to them during the surgery. for most other types
of surgeries my patients are either under general anesthesia or they're sedated to a certain extent,
so the point is i don't usually have somebody who's fully awake and conversant with me,
but during a c-section you better believe mom is awake and conversant.
and it's also not entirely uncommon for the partner who's here to get a little bit woozy
because being in an operating room or seeing what's going on with the surgery may not sit so
well with them so occasionally we do have to bring another stretcher into the operating room to take
out the partner who has either started to pass out or just completely vasovagaled and hit the ground.
and that actually has the potential to be a huge problem because if somebody passes out
in the operating room they could hurt themselves, they could fall into the surgical field,
so when i am providing anesthesia for c-sections not only am i keeping a close eye on all my
normal anesthesia stuff and everything that's going on with mom, but i do also glance over
at the partner on a pretty regular basis just to make sure that they're not going towards the
ground. the next type of surgery that has unique implications for the way that i provide anesthesia
is genitourinary surgery that's done by urologists and also sometimes by gynecologists. for these
types of surgeries we actually recline the patient back in a position called trendelenburg, and in
this case we would say steep trendelenburg meaning that their head is actually down pretty far
so that the operative site can be very easily accessible by the surgeons. the most obvious
consideration for this type of surgery is that we just need to make sure that the patient doesn't
fall off the operating table so we use special types of equipment to make sure that they don't
slide at all on the operating table, and as with most other surgeries we have a very special type
of belt that goes around the patient so that they definitely aren't going anywhere off the table.
as the anesthesiologist one of the things that i keep an extra close eye on when a patient's in
steep trendelenberg is a patient's arm positioning because it's really easy for a patient's arm to
fall off the arm holders, and if a patient's arm falls off it can cause stretching of the
nerves that innervate the rest of the arm that can lead to permanent neurological injury so i keep a
really close eye on the patient's positioning especially during this surgery. another
implication of the surgery where a patient's in steep trendelenburg for the majority of the
surgery is that there can be a lot of swelling of the structures in the head that can lead to
unwanted swelling that affects the eyeballs, the brain, and also the airway structures so that if
there was some type of emergency in the recovery room and i needed to re-intubate a patient,
it would be a lot more difficult if a lot of the airway structures were swollen.
so for those reasons it's really important for me to be mindful of how much fluid i'm giving
to a patient who's in steep trendelenburg during surgery. now independent of what type of surgery
i'm providing anesthesia for, i have to say that i do love having music in the operating room so
long as everybody else who's in the operating room is up for it as well. usually i'm just listening
to music through the small speaker that i set up in the corner of the operating room and it sounds
fine but as somebody who studied audio engineering in college i absolutely love when i'm in an
operating room that has a dedicated receiver that i can control via bluetooth with my phone,
and then these beautiful speakers installed in the ceiling that have absolutely exquisite high
fidelity audio playback. this doesn't change my anesthetic management but it does make me
an especially happy anesthesia resident when i'm in this operating room for the day! well
that wraps up this video, i hope you found it interesting. if you have any feedback i'd love
to read it in the comments below thanks very much for watching and i'll see you next time
so