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