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#Post#: 1957--------------------------------------------------
Anesthesia Chemistry
DIR By: AGelbert
Date: April 6, 2024, 3:15 pm
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by Max Feinstein, MD April 4, 2024 Max Feinstein, MD, is a PGY-4
anesthesiology resident at the Mount Sinai Hospital in New York
City, where he is also chief resident of teaching. His YouTube
channel focuses on perioperative medicine, especially the role
of the anesthesiologist.
[center]What the anesthesia "cocktail"
🧐👨‍🔬 contains & why it's
given[/center]
[center]
HTML https://youtu.be/POLV93ohQcU[/center]
Max Feinstein 149K subscribers 115,061 views Mar 24, 2024
Pharmacology
Anesthesiologists commonly describe giving a "cocktail" to
patients in the minutes prior to surgery. In this video, I
explain the nuances of the medication that makes up this
cocktail (midazolam) and its implications for anesthetic care.
0:00 Start
0:48 Anxiety & amnesia
1:51 Midazolam alone
2:27 Other medications
3:57 Routes of administration
4:31 Truth serum?
5:18 Patient expectations
Following is a transcript:
--- Quote ---
> Feinstein: Anesthesiologists sometimes tell patients that they
are getting a "cocktail" of medications prior to their
procedure, which can sound mysterious and intriguing, when in
reality this cocktail is typically just comprised of a single
medication called midazolam.
>
> My name is Max Feinstein and I'm an anesthesiologist filming
here at the Mount Sinai Hospital in New York City and in this
video I demystify the medications that are administered to
patients prior to procedures. 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.
>
> Before we get too far, just a quick reminder that this video
does not contain medical advice; it's just a YouTube video. If
you need medical advice, you should talk to your doctor.
>
> Midazolam has several very important properties, which are why
anesthesiologists use it. The first of those properties is
anxiolysis, which is just a way of saying that it can reduce a
person's anxiety. This is, of course, very helpful coming into
the operating room if a person is nervous about getting surgery,
which is very often the case for understandable reasons.
>
> Another useful property of midazolam is that it can cause
anterograde amnesia, meaning that patients won't remember
anything after they have received the medication. There is an
important distinction between anterograde amnesia, which means
not remembering something after the medication has been
administered, versus retrograde amnesia, which means not
remembering something prior to the medication being
administered. Midazolam only causes anterograde amnesia, and
even then it doesn't necessarily cause amnesia in all patients.
It can depend on the dose of medication that's given as well as
patient factors like how much they weigh and whether they
consume alcohol, which can have cross-tolerance with midazolam.
>
> Midazolam can be used as a primary anesthetic in cases of
light or moderate sedation where the goal is to have the patient
still conscious and breathing on their own, but just very
relaxed. Midazolam is also used frequently as a precursor to
general anesthesia where a patient is completely unconscious and
not aware of anything that's going on at all. The amount of
midazolam that would need to be administered to produce a depth
of general anesthesia is impractical in most cases, and so for
that reason when patients do receive general anesthesia, there
are other agents that are used such as propofol and sevoflurane.
>
> In a small number of cases, there are other medications that
can be administered either in lieu of or in conjunction with
midazolam. One of those medications that anesthesiologists
sometimes reach for is an opioid called fentanyl, which is also
short-acting. Generally speaking, anesthesiologists like to
reach for short-acting medications because that can help us
maintain fine control over physiologic parameters like heart
rate, blood pressure, and respiratory status.
>
> When we do include fentanyl as part of the anesthesia
cocktail, that's typically because the patient might be in pain
and that might be the reason that they are coming in for
surgery, for example, if they broke a bone. Anesthesiologists do
have to use caution when mixing midazolam with opioids because
together those can cause significant amount of respiratory
suppression. If the plan is for the patient to undergo general
anesthesia, where they're going to be intubated and mechanically
ventilated, then respiratory suppression is kind of a moot
point, but it is very important for patients to be able to
breathe on their own in the time period immediately prior to
undergoing general anesthesia.
>
> Another medication that can be used as part of the anesthesia
cocktail is a very low dose of propofol, which when given in 10
or 20 mg increments, won't produce general anesthesia in an
adult but will actually just produce anxiolysis and perhaps a
bit of amnesia. Having said that, propofol can irritate the vein
where it's injected, which can be a reason to avoid giving more
propofol to an awake patient than they need.
>
> When I mentioned that midazolam is fast-acting, I mean onset
can be 2 minutes or less when given through the IV. It typically
won't last for more than an hour, although again that also
varies depending on the patient. For adult patients, midazolam
is typically administered through an IV, which is placed of
course while the patient is completely awake. But for pediatric
patients who won't tolerate having an IV placed while they are
awake, then we can actually administer an oral form of
midazolam, but it has a longer time of onset closer to around 20
minutes or so, again depending on the dose and the patient.
>
> One of the common misconceptions around the anesthesia
cocktail is that it's a sort of truth serum that causes patients
to just blurt out their deepest darkest secrets. In reality,
midazolam typically just causes patients to feel relaxed, chill
out, maybe giggle a little bit about things that otherwise
aren't that funny, and only extremely rarely do patients become
disinhibited enough to start saying things that perhaps they
wouldn't have said prior to receiving midazolam.
>
> David: I... I feel funny. Is this going to be forever?
>
> Feinstein: But honestly, I have never had a patient actually
disclose anything really that embarrassing while they have been
under the effects of midazolam or any other anesthetic agent.
It's pretty uncommon.
>
> I mentioned that some patients don't remember much, or
anything, after they receive midazolam and I think it's really
important for anesthesiologists to make patients understand that
that may or may not happen once the medication goes in.
Expectation setting is a really important part of the patient
experience after all.
>
> By the same token, I think it's very important for
anesthesiologists to tell patients when they are receiving
midazolam or any other medication that's going to change the way
that they feel. I don't think it's really fair to surprise
patients with medications through their IV without first telling
them that they are about to get something that will change the
way they feel. While the vast majority of patients who receive
midazolam will feel pretty chilled out, there is a small
proportion of patients who have what's called a paradoxical
reaction where they become hyper-energetic after receiving the
medication.
>
> David's Dad: Stay in your seat.
>
> David: [OUTBURST]
>
> Feinstein: If you're a patient watching this video and you're
wondering will you receive midazolam or any other medication as
part of the anesthesia cocktail before your procedure, the
answer is it depends.
>
> Certain aspects of anesthesia practice can vary pretty
considerably depending on factors like who your anesthesiologist
is, what procedure you're coming in for, what medications and
monitoring are available for patients prior to going into the
operating room, and so forth. For these reasons, it wouldn't be
surprising to me to know that a patient who is coming in for,
say, a laparoscopic appendectomy at a certain hospital would
probably not be offered midazolam unless there were extenuating
circumstances. Whereas a different hospital that has different
practice norms would routinely offer midazolam to patients who
are coming in for the same procedure.
>
> I do think this variation in practice begs an important
philosophical question about the involvement that patients have
with regard to the specific medications that they get for their
anesthesia and also the extent to which anesthesiologists are
involving patients in the decision about what medications will
be administered.
>
> On the one hand, I think there is a lot of benefit for
anesthesiologists and their patients to have an open
conversation about what medications will be administered and
why, but then on the other hand that's also not entirely
feasible, especially if a patient is under general anesthesia.
And there is also an argument to be made for the fact that it
can be overwhelming for patients to have to make medical
decisions about the specifics of exactly what they are receiving
as part of their anesthetic plan that might overall make the
experience more anxiety-inducing than it needs to be, as opposed
to simply leaving the decisions to the anesthesiologist about
how best to produce the outcome that the patient desires, for
example, feeling relaxed or being completely unconscious for a
procedure.
>
> If you are a patient and you do have any questions or concerns
about any part of your anesthesia plan, then it's important to
bring it up with your own physician before you undergo your
procedure.
--- End Quote ---
Music:
Subtle Swagger by Ron Gelinas:
/ atmospheric-music-portal
The information in this video is not intended nor implied to be
a substitute for professional medical advice, diagnosis or
treatment. All content, including text, graphics, images, and
information, contained in this video is for general information
purposes only and does not replace a consultation with your own
doctor/health professional.
#Post#: 1958--------------------------------------------------
What medications does an anesthesiologist administer for general
anesthesia? 🤷‍♂️
DIR By: AGelbert
Date: April 6, 2024, 3:21 pm
---------------------------------------------------------
By Max Feinstein, MD May 29, 2021
[center]General anesthesia pharmacology -
👨‍🔬 Medications for induction,
maintenance, & emergence[/center]
[center]
HTML https://youtu.be/hQiHj22VcFI[/center]
Max Feinstein 149K 553,179 views May 29, 2021 Pharmacology
What medications does an anesthesiologist administer for general
anesthesia? 🤷‍♂️ In this video, I
describe the components of a routine anesthetic plan from start
to finish.
0:00 Start
00:24 Overview
02:14 Induction
05:58 Maintenance
07:01 Emergence
The information in this video is not intended nor implied to be
a substitute for professional medical advice, diagnosis or
treatment. All content, including text, graphics, images, and
information, contained in this video is for general information
purposes only and does not replace a consultation with your own
doctor/health professional.
#Anesthesiology #Residency #MedicalSchool
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