Your Healthcare - March 2024

Transcript

• 00:51Welcome to your healthcare.
• 00:53I'm doctor Amit Lahav,
• 00:55and in this show we discussed
• 00:58different types of medical aspects
• 01:01and different type of professions in
• 01:04the field of medicine. Anesthesia.
• 01:06What types of forms of anesthesia?
• 01:09Different procedures, surgeries.
• 01:11Even going to the dentist,
• 01:13you receive some form of an anesthetist.
• 01:17What do you know about the anesthesia
• 01:19that you need to prepare for?
• 01:21How do you get the best
• 01:22out of the anesthesia?
• 01:23What are different forms of anesthesia?
• 01:26Today we are privileged to have
• 01:29with us Doctor Brian Kerner,
• 01:31Director of Regional Anesthesia,
• 01:33Bridgeport Hospital, Assistant Professor,
• 01:35Yale School of Medicine,
• 01:37Department of Anesthesiology,
• 01:38who will enlighten us with all his
• 01:41knowledge regarding the field of anesthesia.
• 01:44What do you need to know?
• 01:45How do you prepare for these procedures
• 01:48with the anesthesia you may require?
• 01:50Stay tuned.
• 01:51Don't fall asleep,
• 01:52because we've got a lot coming
• 01:54for the field of anesthesia.
• 01:55I'm Doctor Amit Lahav.
• 01:57You're watching your healthcare.
• 01:58We'll be right back.
• 02:25Welcome back to Your Healthcare.
• 02:28I'm Doctor Amit Lahab.
• 02:30And today we'll discuss
• 02:31the topic of anesthesia.
• 02:33If we can go to the presentation,
• 02:34please. So anesthesia,
• 02:37it's a big topic but a lot to know about.
• 02:40And again, we are privileged today to
• 02:42have with us doctor Brian Koerner,
• 02:45who will speak to us about
• 02:47anesthesia and the different forms
• 02:48of anesthesia and anesthetic agents.
• 02:53So anesthesia, as just a definition,
• 02:56is a state of controlled temporary loss of
• 02:59sensation or awareness that is induced for
• 03:01medical purposes like procedure, surgery.
• 03:03Like I said, even at the dentist,
• 03:06it may include some or all
• 03:09form of anesthesia, analgesia,
• 03:11paralysis, amnesia,
• 03:12and perhaps a form of unconsciousness.
• 03:17Anesthesia works by blocking signals
• 03:19in the nervous system up to your
• 03:22brain through your spinal cord.
• 03:24The nervous system is made-up of the brain,
• 03:26spinal cord, and the nerves
• 03:28that go to your extremities.
• 03:30Messages from the body travel through
• 03:32the nerves and spinal cord to the brain.
• 03:35Anesthesia blocks pain messages from
• 03:37getting to the brain and thereby you can
• 03:41have these type of procedures in surgery.
• 03:44Anesthesia is a way to control
• 03:46pain during surgery or procedure by
• 03:49using medicine called anesthetics.
• 03:51It can help control your breathing,
• 03:54blood pressure, blood flow,
• 03:55heart rate and rhythm.
• 03:57And these things can be controlled by your
• 04:01anesthesiologist or what we call CRNA.
• 04:05Well, what are some of
• 04:06the types of anesthesia?
• 04:07We'll get into more detail
• 04:08as we go into the show,
• 04:10but just to break it down a little bit,
• 04:12there's local anesthesia,
• 04:14regional anesthesia,
• 04:15and then general anesthesia.
• 04:19For the local anesthesia,
• 04:20it numbs a small part of the body
• 04:22from minor procedures like things
• 04:24for the hand or sometimes toes.
• 04:26For instance, you may be awake
• 04:28during the procedure, or you may also
• 04:30get a sedative and be more asleep.
• 04:33Regional anesthesia blocks pain
• 04:34to a larger part of your body,
• 04:37like your legs or your whole arm,
• 04:39for instance.
• 04:40Epidural spinal anesthesia,
• 04:42and we'll make the differentiation
• 04:44on this with Doctor Kerner later on,
• 04:46is a shot of anesthetic near the
• 04:48spinal cord and the nerve roots.
• 04:50It blocks pain from an entire region
• 04:52of the body such as the belly, hips or both,
• 04:56lower extremities such as your legs.
• 04:58And finally this general anesthesia.
• 05:00This is the one that most people
• 05:02are aware of where you have sort of
• 05:04the tube down helps you breathe,
• 05:06you're on a ventilator and you're
• 05:08completely out for whatever the
• 05:10procedure may be or the surgery
• 05:12that you're undertaking.
• 05:13So local anesthesia here showing
• 05:15is even things like at the dentist,
• 05:17you get a little bit injection for
• 05:19a nerve root to decrease the pain
• 05:21in your mouth.
• 05:22If you have like hand procedures,
• 05:24sometimes things like carpal
• 05:25tunnel or toe procedures,
• 05:27this is a local anesthesia.
• 05:29And now this very small area
• 05:30that needs to be worked on,
• 05:34moving on to regional anesthesia,
• 05:36again it's a bigger area.
• 05:38There's also things called nerve blocks.
• 05:40We'll speak with Doctor
• 05:41Kerner about this as well.
• 05:43And nerve blocks help decrease pain
• 05:45in a certain larger area of the
• 05:48body such as your knee or your arm,
• 05:50for instance.
• 05:51And Speaking of nerve blocks,
• 05:54different type of nerve blocks,
• 05:56some that go into your neck to arm the
• 05:58whole shoulder and upper extremity
• 06:00for things like shoulder procedures
• 06:03or elbow procedures in your leg to
• 06:05numb things like your lower extremity
• 06:07from your knee down for instance.
• 06:09So these blocks help with pain and they
• 06:12have become really a forefront of pain
• 06:16management for even big procedures
• 06:18such as total joint replacements.
• 06:21Then we look at things like
• 06:23epidural spinal anesthesia,
• 06:25we'll make the differentiation on this.
• 06:27And really the indication here is where the
• 06:29needle really goes and it's in your back,
• 06:31in your spine and it helps numb
• 06:34a larger portion of your body,
• 06:36really kind of from your lower
• 06:38extremities even up to your belly.
• 06:40Things like pregnancy or delivering a baby,
• 06:43as well as procedures even again like
• 06:45jaw replacements that can numb the hip,
• 06:47the knee,
• 06:48any procedures in the lower extremity.
• 06:50And then finally,
• 06:52general anesthesia in general means
• 06:54that you are out, completely out,
• 06:56You're not even breathing on your own.
• 06:58There's a tube that goes down
• 07:00your throat and there's actually
• 07:01different versions of this as well.
• 07:03But general anesthesia can be
• 07:06even done for facial procedures
• 07:08where the tube is done not go down
• 07:11your your throat from your mouth,
• 07:13it actually goes from your nose.
• 07:15But again,
• 07:16general anesthesia essentially
• 07:17numbs everything.
• 07:18You are out for the procedure.
• 07:22So what are what determines really the
• 07:25type of anesthesia that you will use?
• 07:27Well, your past and current health,
• 07:30your family history, other surgeries
• 07:32you may have had health problems,
• 07:34heart disease, diabetes can indicate
• 07:37the type of anesthesia example.
• 07:40You may need general anesthesia
• 07:41to ensure your comfort and safety
• 07:44during certain types of bigger,
• 07:45larger procedures.
• 07:46The results of tests such as blood tests,
• 07:50EKG and so forth can also indicate the type
• 07:55procedure that you may or may not need.
• 07:58Well, how should you prepare for anesthesia?
• 07:59We'll discuss this really at
• 08:01at length with Doctor Kerner.
• 08:03You know you got to avoid certain
• 08:05food and drinks a certain amount
• 08:06of hours before the procedure.
• 08:08Smoking is always a risk,
• 08:09not just for wound healing,
• 08:11but also sometimes for the type
• 08:13of anesthesia you may receive.
• 08:15You need to stop taking different
• 08:17type of herbal supplements.
• 08:18Different medications also have
• 08:20to be stopped before surgery.
• 08:25Certain blood pressure,
• 08:26not all but certain blood pressures.
• 08:27Also, these type of medications
• 08:29need to be stopped before the type
• 08:32of anesthesia you may receive.
• 08:33So it's important to prepare for the right
• 08:37anesthesia for your procedure or surgery.
• 08:40Some potential side effects of anesthesia,
• 08:43things like back pain or muscle pain,
• 08:45chills, difficulty urinating, fatigue,
• 08:47something headache or itching,
• 08:50nausea and vomiting are just some few side
• 08:53effects that can occur with anesthesia
• 08:55and obviously these are minimal.
• 08:57We try to minimize all these type of
• 09:00side effects and give you the best
• 09:03opportunity to have the best anesthesia
• 09:05you can with minimal side effects and
• 09:07the best benefits of that anesthesia.
• 09:10So who is at risk for
• 09:12anesthesia complication?
• 09:13Well, the older you are,
• 09:14the more medical conditions you may have.
• 09:16So advanced age, diabetes or
• 09:18kidney disease always plays a role.
• 09:20There's a lot of fluid shifts and
• 09:22different medications that go through
• 09:23your kidneys that can affect your kidneys.
• 09:25And as well, the liver family history,
• 09:28something called malignant hyperthermia
• 09:30and we can discuss this a little bit later.
• 09:34Heart disease,
• 09:34high blood pressure or history of strokes,
• 09:36for instance, can indicate really
• 09:39a higher risk for anesthesia,
• 09:41lung disease,
• 09:42difficulty breathing,
• 09:43COPD or obstructive lung disease,
• 09:47emphysema, obesity,
• 09:48there's more weight on your chest or lungs.
• 09:52Higher body mass index or what we
• 09:54call a BMI can also raise some risks
• 09:57for certain type of anesthesia if
• 09:59you're on any type of neuroleptic
• 10:02or neurological medications.
• 10:03Seizures, sleep apnea,
• 10:04and again smoking creeps up into this,
• 10:07as well as some of the risks that
• 10:11anesthesiologist has to assess
• 10:13before giving you anesthesia.
• 10:15Now,
• 10:15we spoke briefly on malignant hyperthermia.
• 10:18This tends to be rare,
• 10:20but it's terrible if it happens and has
• 10:22to be really approached very quickly.
• 10:24It's a severe reaction to certain
• 10:27drugs used for anesthesia.
• 10:28Again, this tends to be pretty rare,
• 10:30but the anesthesiologist is always ready.
• 10:33It's a severe reaction which typically
• 10:36includes dangerously high body temperature,
• 10:38rigid muscle or spasm,
• 10:41fast heart rate and other symptoms.
• 10:43And this needs to be properly
• 10:45treated very quickly.
• 10:46And that's why sometimes there's
• 10:48carts around the operating room just
• 10:50for these type of rare occasions.
• 10:53But the anesthesiologist is the one
• 10:55that monitors you throughout the
• 10:57procedure and make sure that you
• 10:58are safe and comfortable to whatever
• 11:00procedure or surgery you may have.
• 11:02And this really comes down to
• 11:04monitoring you during anesthesia.
• 11:05You know what are the anesthesiologists
• 11:07looks at not just blood pressure,
• 11:09breathing, but everything else.
• 11:11You they literally monitor you
• 11:13throughout the entire time.
• 11:15Somebody's always looking after you
• 11:17all the time to make sure again you
• 11:19are safe throughout the procedure.
• 11:21So that brings us up to anesthesia.
• 11:24And what I like to do is we're going
• 11:26to take a very short break and we're
• 11:27going to come back and introduce
• 11:29Doctor Brian Kerner again Director of
• 11:32Regional Anesthesia and Bridgeport
• 11:35Hospitals as well as Clinical
• 11:37Assistant Professor at the School
• 11:39of Medicine at Yale. Stay tuned,
• 11:41we'll be right back and we'll
• 11:43enlighten you more about anesthesia.
• 12:16Welcome back to your Healthcare.
• 12:18I'm Doctor Amit Lahab.
• 12:20And again, we're privileged today to have
• 12:22with us one of my colleagues and friends
• 12:25from Bridgeport Hospital system in Yale,
• 12:27New Haven Health Doctor Brian Kerner.
• 12:31Doctor Kerner, thank you very
• 12:33much for being with us here.
• 12:34You know, as director of regional anesthesia,
• 12:37Bridgeport Hospital affiliated with Yale
• 12:39School of Medicine assistant professor,
• 12:41really it's a privilege to have you here.
• 12:44And I think it's a really important topic of,
• 12:46you know, individuals out there really,
• 12:48you know, getting some sort of anesthesia,
• 12:50but you know,
• 12:51not really knowing what you're getting,
• 12:52how to prepare for it,
• 12:53some of the history of anesthesia.
• 12:55So let's begin.
• 12:56Actually,
• 12:56a little bit of your background.
• 12:58Sure. Well, I'll start by saying
• 12:59it's a pleasure to be here.
• 13:01Thank you so much for having me.
• 13:02I'm excited to be here and sort of teach
• 13:04the audience a bit about what anesthesia is.
• 13:07I think there's a lot of
• 13:09misconceptions out there and,
• 13:10you know, beliefs about what we do.
• 13:12So it'll be great to clear
• 13:13a few of those things up.
• 13:14So thank you for having me, my background.
• 13:17I grew up in the Northeast.
• 13:19I have a family at home.
• 13:21I have two young girls,
• 13:24soon to have a third.
• 13:25I did my medical training down
• 13:27in South Florida, the Southeast.
• 13:28Then I spent a year and a half in
• 13:31Seattle doing specialized training,
• 13:33what's known as regional anesthesia.
• 13:35That's really my passion.
• 13:36And then we came back to the Northeast,
• 13:38where I settled into a position
• 13:40with Yale School of Medicine and
• 13:42now mainly at Bridgeport Hospital,
• 13:44Milford Hospital on Park Ave.
• 13:46Medical Center.
• 13:47So you actually have experience throughout
• 13:49I should say the whole continent going
• 13:52from the northeast to the South to
• 13:54the northwest back to the northeast,
• 13:57which actually makes it a a kind of a
• 13:59more complete experience of even what's
• 14:01done throughout the continental USA.
• 14:03Absolutely. There are different
• 14:05cultures you know in medicine and it
• 14:07has been great to experience that.
• 14:08So I feel privileged to have an opportunity
• 14:10to have done that and use those skills
• 14:12that I've learned along the way,
• 14:14you know for patients every day.
• 14:15And again some of your interest is
• 14:17actually in the in regional anesthesia
• 14:19and blocks and I've had the privilege
• 14:21of working with you also in the
• 14:23operating room on different blocks
• 14:24for joint replacements which is proven
• 14:27actually very efficient very well.
• 14:29And that's how you sort of even move
• 14:32these patients through from staying in
• 14:34the hospital to same day type of surgery
• 14:36even for very big type of procedures.
• 14:38So the regional part of anesthesia
• 14:40has become really very important,
• 14:43you know part of of really
• 14:44any surgeon's practice.
• 14:46Absolutely, I it's something I'm
• 14:47that I'm very passionate about.
• 14:49Now, regional anesthesia of course having
• 14:51doing some extra training in that and
• 14:54practice it every day like you said
• 14:55with joint procedures like yourself.
• 14:57But there are two reasons why we
• 14:59would do a regional anesthetic.
• 15:01One would be for pain control afterwards,
• 15:03so you'd receive a full general anesthetic
• 15:05and then this is for pain relief for
• 15:07a period of time after the surgery.
• 15:09But another reason we do regional
• 15:12anesthesia and we will touch more
• 15:14on this along the way is we can
• 15:15avoid a general anesthetic entirely.
• 15:18So there are patients who really are,
• 15:19it's contraindicator really not safe to
• 15:22be doing a full general anesthetic on.
• 15:25So we can just do a regional anesthetic,
• 15:27either a spinal,
• 15:28an epidural or a peripheral neuroblock and
• 15:30we can avoid general anesthesia all together,
• 15:33which can be much safer and people
• 15:35typically feel a lot better afterwards.
• 15:37So let's actually go into your,
• 15:39your first slide of really
• 15:42what is anesthesia,
• 15:43if we can go right the back. Yes.
• 15:45So let's talk a little bit about
• 15:47just starting with the basics.
• 15:48What is anesthesia?
• 15:49Great. Well, like I said,
• 15:51we started talking.
• 15:52I think there's a lot of misconceptions
• 15:54about there about what we do.
• 15:56And for those who haven't seen it
• 15:57in the life of an anesthesiologist,
• 15:59it's actually pretty wild to see
• 16:01the patient go through this process
• 16:03of being in the pre op area fully
• 16:05asleep or unconscious and then wake
• 16:06up as if nothing had happened.
• 16:08So it's good to talk about.
• 16:11I'd like to sort of tell the story of how
• 16:13a patient comes into the operating room,
• 16:15their experience.
• 16:16So for the audience,
• 16:17typically you've spoken to your surgeon
• 16:19maybe a few times before coming in.
• 16:21You know preparation has been made,
• 16:23but typically you haven't spoken
• 16:25to your anesthesiologist before.
• 16:26So you sort of learn what the plan will
• 16:28be and we'll talk about most common
• 16:30surgeries where you do receive that
• 16:32general anesthetic that you talked about,
• 16:34where you're fully asleep or unconscious
• 16:36and then we put that breathing device in.
• 16:39So typically, you get to the operating
• 16:41room around 6:30-ish in the morning,
• 16:44pretty early for scheduled
• 16:45surgery time of 730.
• 16:46You'll arrive,
• 16:47you'll change into a hospital gown,
• 16:50You'll speak to nursing staff.
• 16:52You'll typically get an intravenous
• 16:53line and then you'll speak to the
• 16:55anesthesiologist at some point.
• 16:57And that's when we'll talk about
• 16:58what our plan is and, you know,
• 17:00agree on that.
• 17:01For this procedure,
• 17:02we need a general anesthetic
• 17:04where typically I will say you're
• 17:06asleep for the entire procedure.
• 17:08We'll get into the, you know,
• 17:09specifics of of that.
• 17:11It's not technically sleep,
• 17:13and we'll describe how we
• 17:14put a breathing device in.
• 17:16You may walk up with a sore throat,
• 17:17talk about a few risks,
• 17:20then we'll make sure the operating
• 17:22room is ready at that 7:30 or
• 17:24operating room start comes around,
• 17:26we'll start rolling the patient back.
• 17:27Now when we think about general anesthesia,
• 17:30I want you to think about a few
• 17:32different goals that we have
• 17:33anytime we do an anesthetic,
• 17:35amnesia or inability to form new memories,
• 17:39analgesia or pain control,
• 17:41hopefully of minimal to
• 17:42no pain unconsciousness.
• 17:44So essentially you're unaware of
• 17:46anything that's happening during
• 17:48the procedure and muscle relaxation.
• 17:50So essentially you're not moving while
• 17:51the surgeons are trying to operate.
• 17:53So we'll think about those four things,
• 17:55amnesia, analgesia,
• 17:57unconsciousness and muscle relaxation.
• 18:00So typically we go back to,
• 18:02you know,
• 18:02a story of a patient going through
• 18:04the operating room.
• 18:05We start rolling you back and
• 18:07I may administer a medication
• 18:09called the benzodiazepine,
• 18:10at which point you become
• 18:12a little bit more relaxed,
• 18:14you know,
• 18:15the nerves go away less anxious and
• 18:18that gives some of the amnesia portion
• 18:20of things we call anterograde amnesia.
• 18:22So you don't really remember
• 18:23much after that with a low dose.
• 18:25You may remember things,
• 18:26but it may become a little bit fuzzy.
• 18:28We get you into the operating room,
• 18:30we move you over to the operating room bed,
• 18:32we put our monitors on.
• 18:33That typically includes a blood
• 18:35pressure cuff pulse oximeter to
• 18:37measure your blood oxygen levels.
• 18:39An EKG would measure your heart throughout
• 18:41and we'll typically do a pause at that
• 18:43point and make sure we have the correct
• 18:45patient doing the correct procedure.
• 18:47Absolutely make sure
• 18:48everything's remained safe.
• 18:49Now we'll put an oxygen mask on to fill your
• 18:52lungs up with oxygen and then we're ready.
• 18:55We're at that point.
• 18:56I'll administer a fairly
• 18:57large dose of medication,
• 18:59typically propofol along
• 19:00with a pain medication.
• 19:02And it's like I said,
• 19:04it's pretty wild to see if you
• 19:06haven't seen it within 10 seconds to
• 19:0830 seconds you're completely out,
• 19:09so unconscious your body goes limp
• 19:12and like you said you lose the
• 19:14ability to breathe for yourself.
• 19:16Now this works.
• 19:17Propofol typically works with bonding
• 19:19to different receptors in the brain.
• 19:21GABA A receptors we we call
• 19:24them so an inhibitory,
• 19:26so everything sort of
• 19:27relaxes and is negative.
• 19:28So these these brain waves that you have,
• 19:30the electrical activity,
• 19:31they slow down or they become more organized.
• 19:35Now once you're unconscious,
• 19:36we make sure we can help breathe for you.
• 19:38I'll give you a few breaths
• 19:39with the device we have,
• 19:41similar to what we have here.
• 19:43And once we do that,
• 19:44we give another medication.
• 19:45It's a muscle relaxant,
• 19:46A paralytic that allows us to
• 19:49essentially get that breathing
• 19:51device in easier and allows you to
• 19:53do your pre surgery as you need to.
• 19:55So we've talked about a few different things.
• 19:56Amnesia,
• 19:56the benzodiazepine allows you to not
• 19:59start making memories after that.
• 20:01Unconsciousness and pain control
• 20:03the propofol and other medications
• 20:04we've given during that point.
• 20:06So these
• 20:06medications help also with pain.
• 20:08So you don't feel anything from the
• 20:10procedure or the surgery. Absolutely.
• 20:12And you don't remember anything absolutely.
• 20:14Now the unconsciousness is one thing,
• 20:17but we also want you don't want
• 20:18you to react to the painful stimuli
• 20:20that you have during the procedure.
• 20:21So typically what a surgeon
• 20:24does is stimulating and painful.
• 20:26So we don't, we don't want to
• 20:27see a raise in blood pressure
• 20:28or raise in heart rate etcetera.
• 20:30Those are sort of the tools we use to
• 20:32make sure that you're fully anesthetized.
• 20:34So at this point we've spoken
• 20:36about those goals of anesthesia.
• 20:39But I want to dive a little bit
• 20:41more into the unconsciousness
• 20:42portion of things and and how it's
• 20:44different from a normal sleep cycle.
• 20:46You know, typically when a patient comes in,
• 20:48I will tell them and they'll ask me,
• 20:50will I be asleep for the entire procedure.
• 20:52And while I say yes, you will,
• 20:54it's quite different from normal sleep.
• 20:57So the way that the brain functions
• 21:00essentially is electrical activity.
• 21:02And these medications that we give it
• 21:05inhibits the ability of electrical,
• 21:07electrical activity to communicate
• 21:09one part of the brain to the other.
• 21:12That's the language that the brain speaks.
• 21:13It's electrical activity.
• 21:14Now once the brain can't speak
• 21:16one part to the other,
• 21:18that's when we're not aware anymore.
• 21:20And that's exactly what these medications do.
• 21:22Now let's talk about normal sleep.
• 21:25Everyone's heard of this R.E.M.
• 21:26cycle, non R.E.M. cycle.
• 21:28That's that's typical terms
• 21:29that most have have heard of.
• 21:31R.E.M., R.E.M. is rapid eye movement.
• 21:33So during this period there's an extreme
• 21:35amount of brain activity happening.
• 21:37If we look at an EEG electroencephalogram
• 21:39and we look at the brain waves
• 21:41of a patient under, you know,
• 21:43under sleep,
• 21:44it looks very similar to an awake
• 21:46patient actually.
• 21:47So you're still forming memories,
• 21:48you're still essentially
• 21:49processing everything that has
• 21:50happened throughout the day.
• 21:52You're still hearing things,
• 21:53you're still sensing things.
• 21:54None of that happens during an anesthetic.
• 21:56You're essentially unconscious and
• 21:58it's it's more similar to a a coma like
• 22:02state similar to to death versus sleep.
• 22:05Now if I were to say to a patient all
• 22:07of that when they came in for a surgery,
• 22:10you know you're in a cult reversible
• 22:13medication induced unconsciousness coma,
• 22:14half the patients would walk right
• 22:16out the door of that moment.
• 22:18So while it's simpler to say you're
• 22:19sleeping and it's one way to look at it,
• 22:21it's quite different from sleep.
• 22:24So it it's it's do you can you
• 22:26dream and then remember anything
• 22:28from that or the essentially these
• 22:31medications like you go down,
• 22:32you have anesthesia and the
• 22:33last thing you remember is going
• 22:34into the operating room and
• 22:35when you come out it's all done.
• 22:37That's a good question.
• 22:39Typically you don't dream under anesthesia.
• 22:40So the the like I said the language
• 22:42that the brain speak is this
• 22:44electrical activity and once you
• 22:46block those electrical activity
• 22:47in the gates that allow them,
• 22:50the brain isn't communicating
• 22:50with the other part of the brain.
• 22:52So you're not forming these thoughts.
• 22:54So there's literally a a block of time
• 22:56that you just you can't account for.
• 22:58You were there all of a sudden you
• 23:00wake up in recovery room and it just
• 23:01something happened in the middle.
• 23:02You obviously had a procedure or surgery
• 23:05or something like that and then you just,
• 23:07you don't have that time period
• 23:08sort of in your brain.
• 23:10It's, it's a gap, right.
• 23:11It's pretty amazing to have somebody
• 23:13you know undergo A surgical procedure,
• 23:15an invasive procedure and then wake
• 23:17up hopefully paying for your minimal
• 23:19pain as if nothing had ever happened.
• 23:21And you were mentioning also one
• 23:23of the medications that I'll
• 23:24use really widely is propofol.
• 23:26Propofol is like a Milky white kind
• 23:28of substance that you give through
• 23:30your intravenous or your IV and that
• 23:32actually kind of knocks you out.
• 23:33You said, you know, 10 to 30 seconds.
• 23:35I don't think I've seen any of the
• 23:37patients make it to even 10 seconds.
• 23:39You're completely out.
• 23:40Something is a little bit burned when it
• 23:43goes in and it's very quick as it goes in,
• 23:46but it makes you kind of very comfortable.
• 23:49Some people, you know,
• 23:50relate that also you know the Michael
• 23:52Jackson story where he went to
• 23:54sleep using this type of medication,
• 23:56which is really he was getting anesthesia.
• 23:58There's no dreams, nothing else.
• 24:00And it's it suppresses your breathing
• 24:02and you can if it's not controlled by
• 24:04someone with professional like yourself,
• 24:06it it's really dangerous.
• 24:07But it works extremely well for things
• 24:11like even colonoscopies, endoscopies,
• 24:13I mean gentle anesthesia, you utilize it.
• 24:16Is it short acting, long acting,
• 24:18like how long do you get from,
• 24:20you know, one shot of this stuff?
• 24:22It's relatively short acting.
• 24:24Typically if we give one of
• 24:26those large bolus medications,
• 24:28you know both doses of medications
• 24:30typically within 5 to 10 minutes,
• 24:32you're starting to really wake up.
• 24:34Now it depends how long
• 24:35we've run that medication.
• 24:37Once you're under anesthesia,
• 24:38we keep you in this unconscious
• 24:40state either with prop fall or other
• 24:43medications through your IV or anesthesia,
• 24:45anesthesia, gases and the typically
• 24:47the longer you run those,
• 24:49so the longer the surgical procedure,
• 24:51the longer that stays in your system.
• 24:53So you know with experience,
• 24:55with you know taking all
• 24:57factors into account,
• 24:58we stop those medications at the
• 24:59appropriate time and you're ready to
• 25:01wake up at the end of the procedure.
• 25:02There's always communication
• 25:03with the surgeon, you know,
• 25:05in the procedure and so forth.
• 25:06And you brought something here
• 25:08also because you say you kind of,
• 25:09you bagged the patient, right.
• 25:10You kind of pushed some oxygen in
• 25:12before you you put the tube in.
• 25:14Could we go through some of the stuff
• 25:15to use for a general anesthesia here?
• 25:17Sure. Let's see,
• 25:20this here is called an AMBU bag.
• 25:21It's it's essentially a device where when
• 25:24you squeeze this green portion here,
• 25:26it allows us to breathe the patient.
• 25:27So we we put a mask on and if
• 25:30long as we're squeezing that bag,
• 25:32we're what we called ventilating the patient.
• 25:34So moving air in and out and oxygen
• 25:36is and carbon dioxide of the main
• 25:39medications that we want to move. Again,
• 25:41this is, it's a bag that you can
• 25:43squeeze it in, in this air that's
• 25:44going to come from one side.
• 25:45So you help the patient sort of
• 25:47breathe when you do that exactly,
• 25:48you also have a face mask right there.
• 25:50Too many patients will remember the
• 25:52last thing is the face mask going on and
• 25:55then typically counting back from 10.
• 25:57Now this device here is probably
• 25:59the most critical device we
• 26:01have in an anesthesiologist.
• 26:03If everything around this were to fail,
• 26:05electricity goes out for whatever
• 26:06reason our ventilator and we don't
• 26:08use this for the entire procedures.
• 26:10Patients are placed on ventilators with
• 26:12with which assist with ventilation.
• 26:14But if everything fails this
• 26:16device will save a patient's life.
• 26:18So it's it's critical having
• 26:20any anesthetizing location,
• 26:21it's it's absolutely critical.
• 26:23So that that's then you manually
• 26:25help the patient breathe until the
• 26:27anesthesia comes out and they're and
• 26:29get in control of their own breathing.
• 26:31Absolutely, yes.
• 26:31Now a few of the other things which
• 26:34we brought today we have the our
• 26:37endotracheal tube, this is a large one.
• 26:39So we could see on the television
• 26:42typically it's a little bit
• 26:44smaller than this and this,
• 26:46once you're under anesthesia,
• 26:48once you're unconscious,
• 26:49once you have some analgesia,
• 26:52so pain control and you're relaxed.
• 26:54We would place this essentially
• 26:56down into the trachea and we use
• 26:58another device here which we have,
• 27:00it's called a laryngoscope.
• 27:02It went essentially has a light on the end.
• 27:05It's so we can see into the
• 27:06patient's mouth as we're doing that.
• 27:08And you got to look kind of
• 27:09down the throat exactly because
• 27:10if the tube essentially you
• 27:12know there's two pipes there,
• 27:13one is your esophagus,
• 27:14one is your your trachea.
• 27:16One obviously goes to the stomach,
• 27:17the other goes to the lungs.
• 27:18So you want to make sure this tube
• 27:19goes in the right place to the lungs,
• 27:21otherwise you're pumping
• 27:22air into the stomach.
• 27:23Absolutely. That's critical.
• 27:24It's something that you know you do
• 27:27thousands of time through training
• 27:29and become pretty comfortable with.
• 27:30So, right, That has to be in
• 27:32the correct place and the and
• 27:34the device you're holding there,
• 27:35it's called a laryngeal mascara way.
• 27:37It's it's a much less invasive
• 27:39way of helping a patient breathe
• 27:41during the procedure.
• 27:43So this essentially just sits
• 27:44in the back of your mouth,
• 27:46holds the tongue off the back of
• 27:47your throat and allows us to use
• 27:49our ventilator without putting that
• 27:51stimulating endotracheal tube down
• 27:53South. Essentially the the tube
• 27:55goes down further into your your,
• 27:57your breathing tube essentially your
• 27:59trachea where this kind of sits more
• 28:01just in the back part of your mouth.
• 28:03So patients who have let's say
• 28:06significant sleep apnea or sort
• 28:08of very let's say obese here with
• 28:10short stocking necks for instance,
• 28:13that you're you're afraid that
• 28:14the tongue is going to go back and
• 28:16it's going to hurt their breathing.
• 28:18This is when you potentially use
• 28:20something like this to kind of go back
• 28:22in the back of the throat to move that
• 28:23tongue forward and help them breathe
• 28:25better. Exactly.
• 28:26That's sort of a a secondary indication.
• 28:30One would be we use that
• 28:31just to be less stimulating.
• 28:33But two, if we ever had
• 28:36trouble ventilating that,
• 28:37that can be a rescue device.
• 28:39So it allows us to better
• 28:40ventilate the patient. Exactly.
• 28:42And then I always hear you also
• 28:43when you know when you put some
• 28:45oxygen and and use this face mask,
• 28:47as you sort of put it on your face,
• 28:48you say it may smell like a little like
• 28:51plastic and that's OK that's normal, sure.
• 28:53But you have oxygen flowing through.
• 28:55Absolutely. And and the oxygen
• 28:57that you're kind of giving through,
• 28:58obviously it's not forced oxygen,
• 29:00it's just a little bit higher level of
• 29:02oxygen to kind of expand your lungs,
• 29:04making sure that you're getting that
• 29:05oxygen through your body and your,
• 29:07your red blood cells, right.
• 29:08So typically when we're breathing fresh,
• 29:12you know air here,
• 29:13the oxygen percentage is about 21%.
• 29:15Now when you get to that unconscious state,
• 29:19there's typically a period of which we
• 29:21call apnea or you're no longer breathing.
• 29:23Now in order to extend that safe time
• 29:25that you can be APNIC or not breathing,
• 29:28if we can get the amount of oxygen
• 29:31in your lungs to 100% versus 21%,
• 29:33that extends that up to 10 minutes
• 29:36or so in a normal healthy patient.
• 29:38So just in case we did run
• 29:40into any kind of trouble,
• 29:41it extends that period of time.
• 29:42That's why it's so important that
• 29:44we hold that oxygen mask over your
• 29:46face as you're going to sleep.
• 29:48So just out of curiosity,
• 29:49if let's say you're a swimmer
• 29:50and you want to, you know,
• 29:52go in the pools from the
• 29:53whole length of the pool,
• 29:53if you actually take 100% oxygen beforehand,
• 29:56you can literally hold your breath
• 29:58a lot longer because you're getting
• 29:59more supply of oxygen to your lungs
• 30:01than your breathing fresh air.
• 30:03It's a great question and a great comment.
• 30:06Yes. Typically your oxygen levels
• 30:08will stay higher for longer,
• 30:10but typically it's actually the
• 30:12carbon dioxide which causes people
• 30:14to pass out eventually. Once,
• 30:16once you're not breathing or ventilating,
• 30:18you're moving two different gases,
• 30:20oxygen and carbon dioxide.
• 30:21So once that carbon dioxide level goes up,
• 30:24that's when you pass out and
• 30:25that's when you were on to trouble.
• 30:27Understood, understood.
• 30:28And if we can go actually to the next
• 30:31slide on the levels of anesthesia,
• 30:34let's kind of talk about some
• 30:35of that as well. Sure. So
• 30:39we talked about general anesthesia,
• 30:40right and we briefly touched on regional
• 30:43anesthesia which we will touch on later.
• 30:45But regional anesthesia essentially
• 30:48blocks the pain sensation and may not
• 30:50allow you may you may not be able to
• 30:52move or full full muscle relaxation.
• 30:54Now because of that we may may not
• 30:56need a full general anesthetic.
• 30:58We may not need you to be in completely
• 31:01unconscious or use IV medications to
• 31:03accomplish those other things like analgesia.
• 31:06So we can do procedures under less
• 31:09full body anesthesia than if we
• 31:12hadn't done that regional anesthesia.
• 31:14So, so that's a big benefit there.
• 31:16Now there are procedures where
• 31:18we actually want you relatively
• 31:19awake during the procedure.
• 31:21I know that sounds you know,
• 31:22scary for some,
• 31:23but it's actually a safer way
• 31:25of doing some procedures.
• 31:26First, we can talk about a cataract,
• 31:28I mean that's a pretty much as minimally
• 31:31invasive surgery as we get that
• 31:32either we give very little sedation,
• 31:34minimal sedation where you can
• 31:36talk to us or no sedation,
• 31:38some patients are fine with that.
• 31:40It's just not necessary for
• 31:41that type of procedure.
• 31:42So we don't give more than needed.
• 31:44Now there are other procedures
• 31:46which are more invasive and a
• 31:49few examples would be a carotid.
• 31:51So sometimes the the blood vessels
• 31:53in the neck have some blockages
• 31:56which need to be cleaned out and you
• 31:58go to a vascular surgeon for that.
• 32:00Now in order to monitor that that
• 32:01patient isn't having a stroke or
• 32:03decreased blood flow to their
• 32:04brain during that period,
• 32:05we actually want them relatively awake.
• 32:07So they can sometimes they'll be
• 32:08squeezing a ball or something like that,
• 32:10or we say something and we hear the
• 32:12squeak and we know that their brain
• 32:14on that side of the body isn't having
• 32:16ischemia or diffuse blood flow.
• 32:18So in that's the case,
• 32:19we don't want a full general anesthetic.
• 32:21We want something like a moderate
• 32:22sedation where you're more relaxed,
• 32:24you're calm,
• 32:24but you're able to kind of follow commands.
• 32:27And then like I certain eye surgeries
• 32:30or face surgeries,
• 32:31they want you to be able to smile
• 32:33or lift your eyebrows.
• 32:34They want to make sure they're not
• 32:36affecting any of the nerve crucial
• 32:37nerves in your face or they want
• 32:39to make sure it looks like it's
• 32:41supposed to look so.
• 32:42So those are sort of examples why we
• 32:44wouldn't need a full general anesthetic.
• 32:45We typically call that Mac monitor,
• 32:48anesthesia care.
• 32:49So it's a wide range of sedation
• 32:52where were there were involved,
• 32:54but it's not that full general anesthetic.
• 32:56So again, we want to make a
• 32:57little bit of the distinction
• 32:58also that you know you're awake,
• 33:00but it doesn't mean you remember
• 33:01also everything that's going on.
• 33:03So you're awake,
• 33:04you're not feeling the procedure,
• 33:06you're able to kind of just not be asleep,
• 33:10but you also may not remember
• 33:11part of the procedure as well.
• 33:12And that's really where your expertise
• 33:15come into like kind of making sure
• 33:16that you get more of one versus the
• 33:18other depending on whatever procedure
• 33:20or surgery you have, right. The exactly.
• 33:22And those can be some of the more
• 33:24challenging cases actually for an
• 33:26anesthesiologist sometimes if we are
• 33:28able to fully control your breathing
• 33:30with a breathing tube and a ventilator,
• 33:32it's a little simpler than I having
• 33:35to also worry about or be concerned
• 33:37about an unprotected airway.
• 33:39So essentially a patient during
• 33:40sedation is breathing on their own.
• 33:42We're we're we're not,
• 33:43we don't have any support in their mouth.
• 33:46So it's challenging,
• 33:47but it's an exciting part of our
• 33:50profession and it's just a wide
• 33:51variety of things that we do.
• 33:53And that's also in different
• 33:55procedures, surgeries.
• 33:55You some see the patient kind of go a
• 33:58little bit deeper into sleep and you
• 34:00actually kind of bring them back out again,
• 34:02they may not remember anything,
• 34:04but you just want them to breathe a
• 34:05little bit more on their own rather
• 34:07than sort of kind of stop breathing.
• 34:09So you adjust these medications as
• 34:11appropriately and every patient's different.
• 34:13You know, again,
• 34:14you're monitoring blood pressure,
• 34:15you're monitoring pulse oxometry,
• 34:17you know, how much oxygen to have blood.
• 34:19I mean you, you have all these monitors,
• 34:21you look like a NASA and an expectation,
• 34:23but everything is there for a reason.
• 34:26Absolutely. You know,
• 34:27it's it's the monitoring which has
• 34:29really made anaesthesia a safe practice.
• 34:32Let's talk about you know,
• 34:3350 years ago and we didn't have
• 34:36nearly the amount of monitoring that
• 34:38we have now and anesthesia really
• 34:39is a was a much unsafe for practice.
• 34:42Anesthesia is extremely safe these days.
• 34:44I mean we do you know millions of anesthetics
• 34:47and patients typically do very well.
• 34:49So actually if you bring really
• 34:51the the history of anesthesia,
• 34:53why don't we talk a little bit kind
• 34:55of the the history of anesthesia.
• 34:57I think that's really interesting of
• 34:59kind of how things have changed over,
• 35:01you know, decades of providing anesthesia,
• 35:04right. So actually it's not even decades,
• 35:06centuries and millennia people
• 35:08providing anesthesia for patients.
• 35:10So you know we have records back to
• 35:13the 4000 BC where people are using
• 35:16things like opium and and alcohol and
• 35:19different herbal supplements to to
• 35:22help patients who need medical work.
• 35:25Now I will say during that period it
• 35:27was pretty barbaric and and painful
• 35:30and you know they don't nearly,
• 35:31they didn't nearly have the technology or
• 35:33medical advancements that we have today.
• 35:35But the fact is patient need people
• 35:37needed help from physicians and sometimes
• 35:40those were painful and but but there
• 35:42was sort of the practice of anesthesia
• 35:44for for millennia at this point.
• 35:46Now it isn't probably till the mid
• 35:491800s where we can think of the birth
• 35:52of modern anesthesia and we could
• 35:55think of that essentially ether,
• 35:57the ether diethyl ether is a
• 36:00medication and essentially was used
• 36:02in the 1800s as a recreational drug.
• 36:05So there were what were known
• 36:06as ether parties.
• 36:07People would get together and
• 36:09use ether and have a, you know,
• 36:11have a good time.
• 36:12But what doctors were noticing
• 36:15was that patients,
• 36:16people were hurting themselves
• 36:17and not noticing it.
• 36:19So they weren't experiencing any pain
• 36:20and then they wouldn't notice that they
• 36:22had an injury until the following day.
• 36:24So that's really when physicians starts
• 36:27thinking maybe we can use this for a
• 36:30surgical procedures where they're only
• 36:32using alcohol or you know, you know,
• 36:34hold a piece of wood really tight.
• 36:37You know,
• 36:38maybe we can use this to
• 36:39our advantage and one,
• 36:40make people more comfortable, but two,
• 36:42do cervical procedures that had
• 36:44never been performed before before.
• 36:46Now ether is not used anymore,
• 36:49but derivatives of ether are used every day.
• 36:53We use medications like suvofluorine,
• 36:55desfluorine, ISO,
• 36:56fluorine,
• 36:56and they're all derivatives of ether,
• 36:59diethyl ether,
• 37:00and those are medications that
• 37:01keep people asleep.
• 37:03So that's really more for the gentle
• 37:05anesthesia type of treatment,
• 37:06right? Absolutely.
• 37:07Now around this time period.
• 37:10Additionally, cocaine was being
• 37:13used for medical procedures.
• 37:15So essentially what happened was it
• 37:17landed on the tongue of a physician and
• 37:20they realized their tongue went numb.
• 37:21So the thought was how can we use this
• 37:24to numb different parts of the body?
• 37:26Now we typically don't use cocaine anymore.
• 37:29Sometimes it is used for high
• 37:32procedures and things like that.
• 37:33But for obvious reasons we use medications
• 37:35that are very similar to cocaine.
• 37:37So we use lidocaine, bupivacaine,
• 37:39ropivacaine, Med pivacaine.
• 37:41These are all local anesthetics which
• 37:43function in a very similar way to that.
• 37:46Propofol works in the brain,
• 37:47but they only work on certain ports of
• 37:49either your central nervous system,
• 37:51your spinal cord or your
• 37:52peripheral nervous system.
• 37:53Let's say the nerves will
• 37:55go down to your leg.
• 37:56The way that those function is
• 37:58they work on these proteins,
• 37:59so they bind to proteins on nerves and they
• 38:02form an electrical electrical blockade.
• 38:04So no longer can that electrical
• 38:07system pass through rendering
• 38:09you not able to feel sensation,
• 38:11pain or move that part of your body.
• 38:14So like we've talked about that's
• 38:16extremely useful for us, for example,
• 38:18joint procedures like yourself,
• 38:19a total neuarthroplasty.
• 38:21We're using a combination of
• 38:23regional aesthetic techniques.
• 38:25We're using typically a spinal anesthetic.
• 38:28We're inject numbing medicine
• 38:30into the spinal canal,
• 38:32into the CSF or fluid that surrounds
• 38:34your nerves and that forms that
• 38:36blockade allowing you to you do
• 38:38your surgery potentially without
• 38:39a full genital anesthetic.
• 38:41Patients feel a lot better afterwards.
• 38:43They don't have as much pain afterwards.
• 38:45They're typically able to do
• 38:46rehab a lot quicker,
• 38:47which is important for for
• 38:49you and the recovery process.
• 38:51So we do that part of regional anesthesia.
• 38:53We also do peripheral nerve blocks
• 38:55typically for a knee procedure we'll
• 38:57do the one or two nerve blocks for
• 38:59your knee helps with pain afterwards.
• 39:02That lasts typically anywhere from
• 39:04about 24 hours, maybe up to a few days.
• 39:08Now important to know specifically from
• 39:10those two the variation between the
• 39:13spinal anesthetic and the peripheral
• 39:15neuroblock for a knee operation.
• 39:17Now for a spinal anesthetic,
• 39:18typically you are completely numb.
• 39:20It's if your legs are not there
• 39:21and it can be a sort of a jarring
• 39:23sensation for patients when they
• 39:24wake up from in the recovery room.
• 39:26And we do warn that for patients
• 39:28afterwards they will be numb,
• 39:29they won't be able to feel it does come back.
• 39:31That comes back after about 3-4
• 39:33hours depending on medication.
• 39:35Now for peripheral nerve blocks,
• 39:37you may not have full pain relief.
• 39:40And the reason for that is we don't
• 39:41want to block those motor nerves
• 39:43that go to that part of your body.
• 39:45So you want a patient walking as
• 39:47soon as possible possible after your
• 39:50knee arthroplasty, hip arthroplasty.
• 39:52If we block those, no motor nerves,
• 39:54they're not able to walk properly,
• 39:56they're not able to move,
• 39:57regain motion of that joint.
• 39:59So we try to block that sensation which may
• 40:02not get full pain control, but it helps. Or
• 40:05anything helps that, you know,
• 40:06you have to take less narcotics or
• 40:08narcotics that have pros and cons to it.
• 40:10Obviously they can make you all so dizzy,
• 40:13constipated, you know,
• 40:14having more difficulty kind
• 40:16of with nausea and vomiting.
• 40:19So anything that's regional,
• 40:20which you really been implement,
• 40:22you know implementing this for quite
• 40:24a long time and really instrumental
• 40:25in helping drive this even through the
• 40:28Bridgeport hospital system to to kind
• 40:30of get patients use less narcotics,
• 40:31they are more awake,
• 40:33more comfortable and able to mobilize
• 40:35very quickly after big procedures
• 40:37like like knee replacements and
• 40:39hip replacements for instance.
• 40:40So what I actually want to do is I
• 40:42want to take a short break and I
• 40:44want to dive a little bit into the
• 40:45anesthesia team and then we'll go even
• 40:47specifics on the type of anesthesia again,
• 40:49talk about spinal epidurals for instance,
• 40:52and some of the sort of side effects, risks,
• 40:55benefits of these type of procedures.
• 40:58You're watching your health care.
• 40:59I'm Doctor Amit Lahav here
• 41:01with doctor Brian Kerner.
• 41:02We'll be right back.
• 41:43Welcome back to your healthcare.
• 41:46I'm doctor Amit Lahab here
• 41:48with Doctor Brian Kerner.
• 41:50Anesthesia and we talked a lot about
• 41:53the the history of anesthesia gel,
• 41:55anesthesia, some of the different
• 41:57medications that are used for the
• 41:59state of anesthesia, analgesia,
• 42:00pain relief and so forth.
• 42:03And Doctor Koerner,
• 42:03again thank you very much for being
• 42:06with us really and lighting us a
• 42:07lot about the field of anesthesia.
• 42:09Let's just briefly talk about
• 42:11the anesthesia team,
• 42:12because it's not just you,
• 42:13it's sort of a team approach and we'll
• 42:15go to some specifics in anesthesia
• 42:17and some of the risks involved
• 42:18with different type of procedures.
• 42:20Absolutely. It's a great topic to talk
• 42:22about because one of the most common
• 42:25questions that I get asked when I speak
• 42:27to a patient before surgery is will you
• 42:29be there the entire time And it depends.
• 42:31So there are different practice
• 42:33types within the United States.
• 42:35Some of them are physician only.
• 42:37So if you have a physician
• 42:39only anesthesia practice,
• 42:40it means you will have a
• 42:41physician with you in that room.
• 42:42The entire case,
• 42:43the majority of places within the country
• 42:45are not that they're A-Team model,
• 42:47which is very good as well.
• 42:49I work very,
• 42:50that's the model that I practice in.
• 42:52It means that we work with the physician and
• 42:56a CRNA or a a certified registered nurse,
• 42:59anesthetist or anesthesiology assistant.
• 43:02Now those other fields have gained
• 43:05extra training in anesthesia.
• 43:07So they're experts in the field
• 43:09of anesthesia just going by that
• 43:11a different path whether through
• 43:12nursing or or or otherwise.
• 43:14So typically I will be it's
• 43:18called medical supervision.
• 43:19So I will essentially be in charge
• 43:22of the anesthetics of up to four
• 43:24patients at a time and there's
• 43:25someone else in that room,
• 43:27a highly qualified individual
• 43:28making sure to monitor the patient.
• 43:31But really there's always someone
• 43:32with the patient no matter what. Oh,
• 43:34absolutely. Like I said, one of the
• 43:36standards of care for anesthesia you
• 43:38so you have a qualified individual
• 43:40there for the entire procedure.
• 43:42So it's it's safety is always priority
• 43:44and that's why somebody S always
• 43:46watching the patient, no question.
• 43:47The anesthesia perspective,
• 43:48absolutely. I mean I I work very
• 43:50closely with my team colleagues
• 43:52and I would trust myself or my
• 43:54family member with one as well.
• 43:55They're they're fantastic. You like
• 43:57the commander in chief and you have
• 43:59really excellent people working with you.
• 44:00Absolutely. It's a team absolutely
• 44:02that's even in the surgical field,
• 44:04you know you have physician assistant
• 44:06and nurse practitioners working with the
• 44:08surgeon to help facilitate the surgery
• 44:09and and you know can't do it alone,
• 44:11There's a team model,
• 44:12right. I I think it's important
• 44:14to distinguish that we are
• 44:15available at every point though.
• 44:17So one of the core standards is
• 44:19that if something were to happen,
• 44:21we're immediately available,
• 44:22sometimes within seconds we can
• 44:24be in that room. So absolutely
• 44:25and let's speak briefly also about about
• 44:27the safety of anesthesia and we'll
• 44:29kind of go maybe into some of the,
• 44:30you know, risks and benefits of
• 44:32different type of anesthesia.
• 44:32Absolutely great, great topic.
• 44:34What something we touched on a bit before
• 44:39is how anesthesia is so safe at this time.
• 44:42But 50 years ago it was
• 44:44quite a different ball game.
• 44:46Essentially at that point we were
• 44:48looking at a different monitor,
• 44:50so not the same monitors that we have now.
• 44:53And you'd have to check each of
• 44:54those every 5 minutes or so.
• 44:56So you you would look at the patient's chest,
• 44:59look like they were breathing,
• 45:00look at their skin,
• 45:01make sure they're not blue.
• 45:03You would now only take a blood pressure
• 45:05and that was your your anesthesia
• 45:06monitoring and every 5 minutes or
• 45:08so you would check those things.
• 45:09That's going back 50 years or so.
• 45:11It wasn't until about the 1970s,
• 45:13nineteen 80s where this.
• 45:15This push and safety started to
• 45:17come about and we had the invention
• 45:19of new monitors.
• 45:20One of them,
• 45:21absolutely crucial is the pulse oximeter.
• 45:24That's a device that we put on
• 45:26your finger prior to an anesthetic
• 45:28and it measures that level of
• 45:30oxygen in within your blood.
• 45:31Crucial now it's a standard of care
• 45:33that we monitor that continuously
• 45:35throughout the entire procedure.
• 45:37So instead of having to look at
• 45:38a patient's skin to make sure
• 45:40that they're not losing oxygen,
• 45:41I could,
• 45:41you know,
• 45:42I hear on the monitor at all times
• 45:45that that patient is oxygenating.
• 45:48We use blood pressure,
• 45:49cough every 5 minutes at a maximum,
• 45:51sometimes less than that,
• 45:53sometimes continuously.
• 45:55We also use what's called end title CO2.
• 45:59So we talked a bit about before
• 46:01the different gases that we
• 46:02exchange on a normal basis.
• 46:04One is oxygen and one is carbon dioxide.
• 46:07The best way you can see that we are
• 46:10adequately breathing for a patient
• 46:12is by measuring their carbon dioxide.
• 46:14We have new monitors now essentially there.
• 46:17It's pretty amazing how we're we
• 46:19can look at an EEG continuously
• 46:22during a surgery to see how deep
• 46:24or how anesthetized a patient is.
• 46:27Because studies show that if you are
• 46:29too deep or you have too much anesthesia,
• 46:32you may not do well afterwards either.
• 46:34So it may predispose to things like
• 46:36delirium and things like that.
• 46:38So now we have monitors like
• 46:39that that we can use.
• 46:40So it's the invention,
• 46:41the inclusion of these new modern
• 46:43monitoring systems which allowed anesthesia
• 46:45to be incredibly safe at this time.
• 46:48And you know also for the sake of
• 46:50time let's actually go through like
• 46:53an epidural versus spinal or you know
• 46:56regional 1/2 your body essentially that
• 46:58you're you're giving anesthesia to.
• 47:00So what's the difference between
• 47:02epidural and spinal for instance, sure.
• 47:05So it is medication going to a
• 47:08different location essentially.
• 47:09Now we can do a bolus or a
• 47:12single shot of medication.
• 47:14We can do a catheter,
• 47:15that catheter can go in either location,
• 47:17but it's really the location
• 47:19of that medication which has
• 47:20its have a different effect.
• 47:21Typically a spinal anesthetic
• 47:23is much a stronger effect.
• 47:25So it happens almost instantly,
• 47:26within a few seconds or in a few minutes,
• 47:29you're completely numb and
• 47:31it's very reliable.
• 47:32Epidural tends to take a little bit longer.
• 47:34The reason for that it's,
• 47:35it's outside that spinal fluid.
• 47:38So you have a layer of tissue
• 47:40called the dura matter.
• 47:41The epidural is outside that gera matter.
• 47:43The spinal is inside that dura so or
• 47:46the sub arachnoid space we call it.
• 47:48It's where all that fluid is.
• 47:49Now both can achieve the same effect,
• 47:53but typically spinal's a little bit
• 47:55more reliable and a lot stronger.
• 47:57Now we go ahead it it is in your lower back,
• 48:00this is really kind of where the,
• 48:01the needle goes in order to
• 48:03do an epidural or a spinal,
• 48:04correct. Now it can be low back as
• 48:06we can see from the model here or
• 48:09we can put epidurals higher up.
• 48:11Now the reason we can do an epidural
• 48:13higher up and not a spinal is
• 48:16because it's much safer to enter
• 48:18that spinal column at a lower level.
• 48:20Essentially your your spinal cord
• 48:22ends at a a, the high lumbar spine,
• 48:25so the mid back, lower mid back.
• 48:27And I sometimes explain this and I
• 48:30had a patient recently tell me and I
• 48:32I say that it's a bundle of nerves,
• 48:35your spinal cord and a point it ends
• 48:37and you just have strands of cords,
• 48:39split strands of nerves floating in liquid.
• 48:42And that's why it's safe to enter
• 48:44in that point,
• 48:45because instead of taking a chance
• 48:46of going into one of the nerves,
• 48:48they essentially get pushed away.
• 48:51We call that the Cordia Aquino
• 48:52or the horse's tail.
• 48:55And if you bought a kit here also
• 48:58just maybe show quickly what do
• 49:00you have there in the kit for
• 49:02sure. For us,
• 49:03we have a standard epidural kit here.
• 49:06I'm not sure if the camera can focus
• 49:08in and everything is pretty small here,
• 49:10but we have a catheter here
• 49:12technically in a pregnant patient,
• 49:15patient who is laboring and
• 49:16we want to have some form of
• 49:18analgesia or pain control,
• 49:20which many prefer to have.
• 49:22We would insert this catheter
• 49:24into the epidural space.
• 49:26We do that via certain needles
• 49:29which we have here in the kit.
• 49:31We use that with different syringes and
• 49:33we have a spinal needle here as well.
• 49:36That spinal needle essentially
• 49:38is what we take and we enter
• 49:40into the spinal column through
• 49:42the the spaces in your back.
• 49:44So again, these needles
• 49:45actually are also very thin,
• 49:47very small because you don't need a big
• 49:49hole to actually give these medications.
• 49:51You just need a small entrance
• 49:52and just to get and you don't even
• 49:55have to give much of anything.
• 49:56You give a few CCS and you're
• 49:58or a few millimeter milliliters
• 50:00actually and that's all you need.
• 50:02And then you're numb for the waist down,
• 50:04right. Our our goal is to use the
• 50:06smallest needle as possible and
• 50:07typically the IV that you receive in
• 50:10the intravenous line that you receive in
• 50:12the pre op area that's typically bigger,
• 50:14almost always bigger than the needle
• 50:15that we would use in your back.
• 50:16So we want to use a small needle.
• 50:18The reason for that is you can
• 50:20have less complications,
• 50:20so you can have less chances
• 50:23of getting a headache,
• 50:23maybe less chances of bleeding,
• 50:25things like that.
• 50:26So yes we use the smallest needle possible.
• 50:28So how do you prepare for anaesthesia?
• 50:30You know what, what should we tell patients,
• 50:33you know, to prepare for general versus
• 50:35spinal versus just having a procedure done?
• 50:38Sure. I I think the most important thing
• 50:40is that you have a good relationship
• 50:42with the primary care doctor.
• 50:43That primary contractor who knows
• 50:45you over a long period of time
• 50:48could essentially manage your your,
• 50:50your medical problems and then if needed
• 50:52sends you to different specialists.
• 50:54So make sure that everything is
• 50:56what we would call optimized.
• 50:58So we want a patient in the best condition
• 51:01possible going into that procedure.
• 51:03Things such as losing weight,
• 51:04things such as stopping smoking,
• 51:07getting diabetes under control,
• 51:09things like that,
• 51:10they can really make a difference
• 51:13for a patient undergoing surgery.
• 51:16And in diabetes, there are certain,
• 51:18no, you know, this is something new
• 51:19that actually came up, some of these,
• 51:21some of these diabetic medications
• 51:23actually have to be stopped before
• 51:25the procedure and some have to be
• 51:27stopped even a week before the
• 51:29procedure for certain reasons.
• 51:30You know why,
• 51:32right. So I think you're referencing
• 51:33Ozempic and that's probably in every,
• 51:35you know, not only health magazine
• 51:37but also lifestyle magazine
• 51:38within the country at this point.
• 51:40So, you know, it's being spoken about it.
• 51:42It's being used more and more frequently now.
• 51:44And the reason for that is while
• 51:46this medication was used for a long
• 51:48time for diabetes, like you said,
• 51:49there's also a new indication
• 51:51and maybe new indications coming.
• 51:54It's now being used as a weight
• 51:55loss medication for people who
• 51:57don't have diabetes.
• 51:58There was a trial recently,
• 52:00almost 20,000 patients and people were
• 52:03using Ozempic for three years and they
• 52:05were having a 10% weight loss during
• 52:08that period and they were having a
• 52:1020% decrease in cardiovascular event.
• 52:12So we're going to see more and
• 52:14more patients on this medication.
• 52:16Now the way it works is in
• 52:19multiple different ways,
• 52:20but one it increases the insulin in
• 52:22your body so it breaks things down,
• 52:23hence weight loss.
• 52:24You think less about food,
• 52:26but important for anesthesia is it
• 52:28induces what's known as a gastroparesis,
• 52:31the slong of the digestive tract.
• 52:34What that what that means is
• 52:36typically you're told to not eat
• 52:38or drink anything for a period
• 52:39of time before an anesthetic.
• 52:41The reason for that is we want all
• 52:43that food that you've been eating
• 52:45to pass through to a safe point.
• 52:47One of the most serious complications
• 52:50that can happen during anesthetic,
• 52:52it's called aspiration.
• 52:53Essentially what that is,
• 52:55is contacts from your stunning
• 52:57stomach going up and then going
• 52:58down the wrong pipe into your lungs.
• 53:00That can cause pneumonia and really
• 53:03serious health complications for a patient.
• 53:05So when patients are taking Ozempic,
• 53:08they have this medically
• 53:10induced gastroparesis.
• 53:11So slowly the digestive tract and
• 53:13they're more likely to have food
• 53:15in their stomach when if they
• 53:17weren't on that medication they
• 53:18wouldn't that wouldn't be there.
• 53:20So the recommendations are right now
• 53:22if you're on a once weekly medication
• 53:24that you only that you missed the dose
• 53:27prior so you don't take it within
• 53:29a week of anesthesia and that's the
• 53:31decrease that risk of aspiration.
• 53:33And let's speak in the last few minutes
• 53:35even though we have some of the, you know,
• 53:37the risks that we try to to decrease,
• 53:39you know, things like people say
• 53:41you don't nausea or vomiting,
• 53:42headaches, things like that. Sure.
• 53:45Nausea is one of the things that people
• 53:47really do not like to experience
• 53:49after anesthesia and it's somewhat of
• 53:50a common complication that we have.
• 53:52You know they they've done studies
• 53:54where they essentially ask people
• 53:56would you rather be in pain or
• 53:58nauseous after surgery and almost
• 53:59everybody says I'd rather be in pain.
• 54:02Yeah, the combination of the two is horrible.
• 54:05So you know we have protocols our
• 54:07our institution there are what
• 54:09we know as guidelines,
• 54:10so recommendations that we give multiple
• 54:13different anti nausea medications
• 54:15to try to decrease the chance that
• 54:18a patient will be nauseous for
• 54:19anesthesia. And again nausea also is
• 54:21is you know the the higher level of
• 54:23anesthesia you get like general anesthesia
• 54:25carries a little bit more of that
• 54:26risk than a regional anesthesia like
• 54:28a spinal or nerve blocks or regional
• 54:31absolutely great point.
• 54:32So if we utilize that
• 54:34that regional anesthesia,
• 54:35often we don't have to use that same
• 54:37level of general anesthesia or same
• 54:39medications and people are less
• 54:41likely to be nauseous afterwards.
• 54:43So that's again one of the reasons
• 54:44that you know we try to kind of sort
• 54:46of minimize some of the anesthesia.
• 54:48You're getting it going more towards
• 54:49blocks or regional anesthesia which
• 54:51is really even an orthopaedic spin
• 54:52sort of the trend and it works better.
• 54:54And this is really where your
• 54:56expertise come in handy.
• 54:57This is what you do in order to get
• 54:59the patient safely through there and
• 55:01more comfortably through it as well.
• 55:03You know even things like like like
• 55:04headache and a lot of people say you
• 55:06know am I going to be in pain or
• 55:07how much pain am I going to have?
• 55:09And this is really where again
• 55:11your expertise come in handy.
• 55:12The blocks that you give that that
• 55:14regional or aerial anesthesia that
• 55:16you provide the patients makes a big
• 55:19difference on mobilizing the patient,
• 55:21make him feel more comfortable
• 55:23that way and then less use of again
• 55:26narcotics and other medications that
• 55:28can cause some some side effects.
• 55:30Is there anything else would you
• 55:31say the patient you know how do
• 55:33you prepare for anesthesia?
• 55:33We spoke about optimization with your
• 55:36primary care, your medical comorbidities,
• 55:37make sure your blood pressure is good,
• 55:39estrogenation, whatever you can do.
• 55:41Your diabetes is well controlled
• 55:42to decrease some of those risks.
• 55:45Anything else you would add to the
• 55:47patient to maybe to relax, you know,
• 55:48you're in good hands, so to speak.
• 55:50Absolutely.
• 55:5111, I would say is stop smoking.
• 55:54Having surgery is a great opportunity
• 55:55to sort of counsel patients and there
• 55:57are higher risks for patients who
• 55:59smoke during the preoperative period.
• 56:00So if you're able to,
• 56:01it's a good time to stop.
• 56:02We know it's hard.
• 56:03We know everybody's not going to do that,
• 56:05but it's a great opportunity to try that.
• 56:07Now as far as relaxing,
• 56:10take it easy night before,
• 56:11watch a movie, try to get some sleep.
• 56:13If you don't,
• 56:14we'll get you a nice nap we say.
• 56:17And really anesthesia is an
• 56:19incredibly safe thing these days.
• 56:20I mean people do incredibly well.
• 56:23So
• 56:23well in the last,
• 56:25you know couple minutes here again
• 56:27I want to thank doctor Brian Kerner
• 56:29really Director of Regional anesthesia,
• 56:31Bridgeport Hospitals,
• 56:32Associate Professor at Yale School
• 56:35of Medicine Department of Anesthesia.
• 56:37Really it's been a privilege working
• 56:40alongside with him providing patients
• 56:42excellent care blocks, pain relief,
• 56:45safety, decreasing those risks,
• 56:47optimizing those benefits.
• 56:48So you can really undergo the procedure
• 56:51and focus on on really getting better.
• 56:53We spoke with some of the risks
• 56:54and benefits of anesthesia,
• 56:55different types of anesthesia.
• 56:57And really, how do you prepare for your
• 57:00anesthetic with the team of leading
• 57:03the team by the anesthesiologist.
• 57:06This is your healthcare.
• 57:08You've been watching the field of anesthesia.
• 57:11Again, thank you to doctor Brian
• 57:13Kerner for being here with us.
• 57:15As I always say,
• 57:16the more you know about your health,
• 57:17the better you are,
• 57:19but making the appropriate
• 57:20decision for yourself.
• 57:21I'm Doctor Mila Hav,
• 57:22and thank you for watching.