Why patients are paralyzed for surgery (and how it's reversed)

[@BugnBuddysMom]

I appreciate these videos. You finally explained what probably happened to me, which resulted in the most terrifying night of my life. I had an open heller myotomy 9 years ago, had complications, went back in the OR and woke up, in the ICU on a ventilator, totally paralyzed. I could hear, AND feel pain, but couldn't move. The nurse who was 1 on 1 with me told another nurse that I would be a full code by morning... she talked about me in the PAST TENSE. Eventually I was able to make little twitches, which she noted, but didn't try to investigate. Another nurse figured it out. I am a Chronic Kidney disease patient. That was my 35th surgery, And thankfully, that was the only time that happened. So, just remember that we can still hear, even if we can't respond!!!! Thank you!!!!!

[@nicholasthompson8772]

Were you a DNR? Because becoming a full code by morning makes no sense at all

[@hannahrosa5485]

TY. I'll never forget having the paralyzing agent pushed seconds before the anesthesia, which seemed like many seconds. Terrifying to say the least.

[@fko1]

I find this whole topic of anesthesia fascinating. I recently had a hernia repair and would have loved to have had the time to sit and chat with the anesthesiologist.

[@lesleynyborg2093]

Max, I appreciate your videos. I had a lumpectomy on 5/25 and your videos really helped to inform me. I will have robotic surgery later this summer for kidney cancer and the info in this video was informative. One thing I'd like to see you address is the memory loss associated with anesthesia. For example, I remember being wheeled to operation room #8 and noting there were people waiting around, I don't remember being transferred to the operating table but I remember them asking me to scoot up and my arms being velcroed down. I don't remember anything in the Pacu but remember one of the doctors seeing me postop in my preop room. I do not remember dressing or being taken down to my car or part of the way home. I made multiple calls and my husband said I was acting "normal" but don't remember much until we were 1/2 way home. It was surreal!

[@Fhshaoaksbd]

He may have addressed this in a prior video. It sounds like you're describing the effects of Versed/Midazolam. It's a sedative drug thats typically given prior to surgery to help with anxiety and it also has anterograde amnestic effects. It makes it where you can't form memories from the moment it's given onward (for a few hours).

[@rm-dc6tx]

Congratulations on completing your residency program. I look forward to more videos covering the next phase of your Anesthesiology career.

[@u_luintel]

Could you make a video on post operative sore throat?

[@Ms.Opinionated]

Great idea!!!!

[@Kopitskid78]

I was told by my anesthesiologist that sore throats after are related to breathing tube!

[@Ms.Opinionated]

@@Kopitskid78 I heard the same thing, but I want to know why.

[@tinamorris01]

Sore throats come from irritation so when the breathing tube is in your airway for a period of time it causes irritation.

[@sheelaghhalstead4549]

I want to know whether breathing tubes are always used. I recently had parathyroid surgery and experienced the sore throat for a few days. But I don't recall feeling any of that after a laminectomy about 15 years ago.

[@joshplunkett2932]

Love your channel. I dove into your channel and a few others for about a week or 2 before surgery a month ago to educate myself a bit on the anesthesia process and what to expect. It really did help calm me down before surgery being somewhat informed in the process so Thank you!! Question time. Last month I a 37 year old male and I had a Roboticaly Assisted Colectomy and they removed 10 inches of my Colon and I also had an Interlooping Fistula to my Bladder. Originally my Surgery was expected to be 3 hours but ended up being nearly 6 hours due to me still having an active infection (my White Blood Cell Count was 26 when I went into surgery) and they had to spend the extra time clearing all the infection out first. When I woke up in Recovery my whole body was shaking, my legs were kicking, and I was screaming. They ended up having to remedicate me with 2 more rounds of Fentanyl and a few other things. I don't remember moving to my regular hospital room. So what do you think happened? Was it possibly because my surgery ended up being nearly double the length and maybe they didn't quite have my pain meds leveled out for the extended time? Thanks again for all the work you do for your channel!

[@darriontunstall3708]

Awesome video man! That was amazing and cool, I learned a lot! I always learn a lot from you! You rock man! I really enjoy donating to the anesthesiologist Foundation, since it was hard for me to go to college because of my cerebral palsy, I really wanted to be a anesthesiologist physician!

[@kevindavis8175]

Awesome. Congrats on graduating residency by the way!

[@Rebander1549]

Thank you for another excellent video! Your information does help explain so much of what I have endured while under anesthesia. I had heart valve repair in 2005 and clearly remember that event. The anesthesiologist is the one who basically runs the show during cardiac surgery. I'm 64 now but I do remember when I was 6 and had my tonsils removed. The anesthesia was ether and it was so horrific! 😮 And although anesthesia has vastly improved, all I could think about after the heart surgery was how brutal it was. My body was violated and pain medication didn't dull that feeling. I have recovered beautifully from the surgery and it has been 18 years since the repair! I have found that the better informed my medical team is about me and my health the better the recovery from surgery is. It's been so interesting to watch your show. 😊

[@laratheplanespotter]

I’d love a video about genetic predisposition to anaesthesia complications. Please 🙏🏻?

[@uhalfxeofficial7529]

Hello Max, What is the most complex surgery you have done and what were some of the drugs you used to anesthetize the patient throughout the operation?

[@davidadams9391]

Always good! Always interesting! A patient from Texas

[@FCBoulder]

Really fantastic video, Doc. Light-hearted, informative, enjoyable. Thank you for making this!

[@Christine-yh8hq]

Thank you for this very informative video Max. It is wonderful to have access to your expertise!

[@SJR_Media_Group]

I'm a frequent flyer with 6 Lumbar surgeries, last was fusions on 12 levels starting at S1/L5, 1 neck surgery, and 1 hernia surgery. I always joked with my Anesthesiologists about the paralyzing agents. I quipped about leaving me with enough function to use my fingers to signal if something was going wrong. What follows is amnesia where even going under is not recalled. Finger movement least concern.

[@ACB487]

Interestingly, for most spinal surgeries the paralytic is usually only for intubation. They purposefully don’t leave the patient paralyzed so they can monitor muscle twitches across the body by placing many probes into the muscles in order to ensure that they haven’t affected the spinal cord. Anesthesiologists generally go as far as avoiding even anesthetic gases, since they can affect reflexes and alter the findings from the probes, and instead use an anesthetic modality called Total IV Anesthesia (TIVA).

[@SJR_Media_Group]

@@ACB487 Thanks for comment. Even frequent flyers in the OR can learn new things everyday.

[@nextgen00]

Thanks a Lot for your teaching and the fact that u share it with us Max. Im a Swiss Biomédical engineer, and your videos are really helping me and growing my knowledge 🙏

[@karyannfontaine8757]

Thank you for information on the need to paralyze the patient and how it is done. Delicate surgery does require medication so that they do not move. The anesthesiologist has a most important part in medical procedures.

[@helookalikaman79]

One surgery I had, at the end I woke up aware of sounds, but could not move, i couldn't breathe, it took all my focus to get mouth open, and some dip closed it.... I woke up in pre-op... and wanted to go home immediatelty from the way I had been treated pre-op... Looking back I should have canceled the surgery....

[@DudeWhoSaysDeez]

It makes sense that so many of these tools automate and better measure aspects of the patient compared to what a human could do

[@waelfadlallah8939]

You are great, sir 🙏

[@At_MiguelRodriguez]

Excellent video Max, stumbled upon your channel and love the content. Question, my hospital uses a lot of Etomidate and Rocuronium for RSI. What are your thoughts on this combination for rapid induction?

[@GreggBB]

Excellent video! Really enjoyed all the information

[@insomniaperennis3949]

Thank you as always for your videos

[@wrongwayscout]

great video! this stuff is all so fascinating. I understand as a doctor you're used to seeing the human body but for regular folks seeing the inside of someone's throat (1:26) is a bit of a shock 😅, maybe you could put a warning beforehand next time.

[@Fornackx]

Thank you for this informative video. In the past I had to undergo some surgery that required muscle relexants to be administered. Before surgery one does get information about the procedures but strangely enough you tend to miss details about that as a patient, or forget many details quite soon. Fun bonus fact: I am one of the relatively few people on this planet to actually have produced both Rocuroniumbromide and Sugammadex as my daily job.

[@Maxmaxmax63]

Just got out of my ENT surgery with mt sinai. Although you weren’t my anesthesiologist!

[@gothafloxacin]

Funnily enough ive had a full liver transplant and didnt really have a sore throat much at all after. Getting NJ tubes placed though is way worse for me personally.

[@allisonmintz4369]

I had that shock test. Very painful. Ultimately, it was useless because I was diagnosed with the rare vascular neurological condition of Cavernous Malformation.

[@mynameisbrigham]

I wouldn't argue it was useless. It probably eliminated a few possibilities that allowed the doctors to narrow down your condition. Regardless, I hope all goes well for you!

[@morganschiller2288]

Whoever was doing your nerve stim was an asshole then. There are settings for needle placement. Your not supposed to go above 40mA (which is VERY painful. I have done it to myself many times) and the sticky pads that you can go up to 80mA. I don’t I start at 10mA in the ulnar nerve and maybe 20mA in the post tibial nerve. I caught A LOT of crap by my colleagues for doing this. But I know my patients didn’t suffer. I like to see a robust signal. But also doing this on myself with needles and stickies. I noticed at 40mA I had lingering nerve pain in my ankles for two weeks. My patients get the lowest mA. Some of my colleagues would make em’ dance on the table. I think thats barbaric. I absolutely hate stickin’ em. But its a necessity in spine surgery.

[@kathyfullarton8126]

During spinal surgery( lamenectomy and PLIF), if neuromonitoring is being done, does that prevent the use of paralyzing drugs? If so, is a deeper level of anaesthesia used?

[@LauraAileen]

I’m not an expert on anaesthesia but I do do neuromonitoring! Our requirements from anaesthesia are no paralytics and no use of inhalational gases as that can obliterate the signals we are looking for. So we ask for the use of TIVA (total intravenous anaesthesia), usually propofol and remifentanyl. Therefore it’s not deeper anaesthesia but a different regime.

[@kathyfullarton8126]

@@LauraAileen thank you for the information. Thank you for the work that you do.....so vital to spine surgery.

[@morganschiller2288]

We ask for a short acting paralytic for intubation. Roc is our standard because it normally wears off in time for the real surgical manipulation like screw stimming and decompressing around the nerve roots.

[@morganschiller2288]

Holy crap another iom tech’s on here👋 we are SO rare!

[@faxriddinikromidinov6020]

Please make a video about inhalation anesthetics

[@morganschiller2288]

For some reason I was having an AWFUL time understanding what a TOF was. I had a really hard time understanding it on my Cadwell.

[@kevindavis8175]

Is that the same concept as therapeutic electrical stimulation?

[@morganschiller2288]

Eh close, with a TENS unit your blocking pain signals. I tell my patients when I’m doing their SSEP’s its “ like a really expensive tens unit”

[@NH-je1up]

Llama scrub hat appreciation comment.

[@kyledeitz2760]

Wish we could use suggammadex every time where I work. It’s an awesome medication. Hopefully administrators will see the huge benefit of it in the future.

[@nathanbimrose7574]

Hey, I don’t get all the notifications for your videos! This is a shame since I seek these out as inspiration for advancing my medical career; others doubtless do also. Is the algorithm hiding your content?

[@mattbrown817]

He said what? The electric chair for his patients? Hello 911?

[@jillthompson4280]

Do bis scores have a different monitoring system? What is involved with that and how accurate is it?

[@teamqueasy]

BIS monitoring has nothing to do with paralyzing patients. it's a depth of anesthesia monitor system which s at best a random number generator with a 20-second lag. There are better monitoring equipment on the market.

[@jillthompson4280]

@@teamqueasy thanks for explaining 🎯

[@morganschiller2288]

I’m satisfied, this is probably the closest I will get to an ionm vid outta my Anesthesia buddy.

[@josiahhorner6705]

Is their any special considerations for a person who has AD?

[@BirdiesGoCherp]

As crazy at it seems, almost all surgeries going in at my university hospital have no Neuromuscular monitoring and rarely do we have capnographs.

[@brettlamont4965]

Could you do a segment on nerve monitoring for longer term surgery for placement and movement. I had a spinal surgery and ended up with temporary brachial plexi damage eventhough they did monitoring and moved me during the surgery. Complete right arm paralysis for about five weeks. Glad they were doing monitoring otherwise damage could have been permanent. They don’t explain those things on longer surgeries.

[@morganschiller2288]

Who did your monitoring!!!! You would see your right (or left ) UN or MN SSEP’s dump off like a rock. First your N9 goes away and it falls apart from there! We have an alert criteria, if there is a 50% loss in amplitude or a 10% decrease in latency we HAVE to tell the surgeon. You have to report it. You can potentially have brachial plexus injuries in every type of spine surgery, from an ALIF from being burrito’ed all the way to being on an open Jackson for a PLIF and if your arms aren’t at the right angles the you have damage. As a iom tech myself I am so so so very sorry this happened to you! Its shocking that the oversight you had on the case and your iom tech failed to see it. On the Cadwell everything turns yellow or red (based on the settings) on the M5 everything turns yellow. So they knew there was a loss. Your also supposed to post op you and make sure you can move everything and document it if you don’t. This makes me mad as shit because your tech was probably dickin’ around on their phone.

[@morganschiller2288]

Glad they were doing monitoring otherwise damage could have been permanent. They don’t explain those things on longer surgeries. When it comes up as a loss of ssep’s we don’t know how long its going to last and this really needs to be the gold standard for spine surgery. I just don’t know why you needed to be moved. You get intubated on the bed you roll in on. We place out needles, you get flipped, we run our baselines and off you go. I have only been doing this for two years, but I’ve never seen a brachial plexus injury on a lumbar case. Just a loss of motors on an acdf. Max can back me up on this. The younger Anesthesia crowd is learning more about IONM. The old timers still don’t understand it for the most part. Its sickening when patients lose their signals because I’m personally responsible for it.

[@morganschiller2288]

Your doc should tell you if your having ionm. Its a little weird to wake up with poke marks everywhere and not understanding why. People get freaked out when we place needles in the scalp and they wake up with blood running down their face.

[@brettlamont4965]

@@morganschiller2288 they told me they repositioned me after the loss of signals. Sorry about not being clear on that. It was very scary as they had to rule out a stroke as well. Made the recovery process slow as i could only support myself with one arm. Fortunate that the docs involved did the monitoring. It was a revision surgery so it was longer than most back surgeries.

[@JakStat]

Why it took so long in the United States to start using sugammadex? Feels weird to hear it described as a new thing.

[@benbookworm]

If you ever need a "why" for American medicine, the answer is usually money. In this case especially, because sugammadex is only available here as brand-name Bridion. Meds are often considered "new" until there's a generic available.

[@briansomething5987]

He didn't say new, he said more recent than the other drugs. The FDA initially rejected the new drug application in 2008, then finally approved it in 2015.

[@teamqueasy]

It's probably the most expensive drug in anesthesia.

[@morganschiller2288]

Sugammadex is more expensive that neostigmine. First time I knew I had sugammadex was for an op in 2011. Its all in the hospital you go to and what they carry

[@allisonmintz4369]

Do a video about Cavernous Malformation.

[@Yahriel]

This is cool. I recently had a major surgery that involved microsurgery on nerves and blood vessels. I'm guessing that's something that'd require complete paralysis? Can just parts of a patient be paralyzed, similar to a nerve block? Or does it not make sense to do that (if it's even possible) since motion isn't isolated to just the part(s) that moved?

[@NithinJune]

just curious, when you do demos like this, who pays for the items you use?

[@Rose-qr4xn]

1st General Anesthesia: “But for Adam, no suitable helper, was found. So the Lord God caused the man to fall into a deep sleep; and while he was sleeping, he took one of the man’s ribs and closed up the place with flesh. Then the Lord God made a woman from the rib he had taken out of the man, and he brought her to the man.” Genesis 2:21-22. There you have it!! God himself was the first anesthesiologist!

[@shanzaayub5824]

Sir why are there two nanes for muscle blockers ? ( paralyzing agents and muscle relaxants ) i was asking this from an anesthesia tech that why do they need muscle relaxants when theyre using paralyzing ahents . His answer was muscle relaxants are used due to post operative pain . Now im confused if sux is a muscle relaxant then why is it a paralyzing agent ? Im wondering why couldnt i move my limbs when they were switching me to bed from the gurney ? Was it paralyzing agent or what im so lost here 😂 im sorry im being inquisitive cause im not told anything and i dont remember much and it bothers my peace of mind 😅😅😅 thank you for helping us learn

[@benbookworm]

Part of the difference can be in their method of action. There as several parts of the neuromuscular juntion that can be acted to on to reduce the strength or frequency of action potentials. Drugs that target these different aspects will behave differently. For further reading: en.wikipedia.org/wiki/Muscle_relaxant go to the Neuromuscular blockers section.

[@talpa6969]

Paralyzing agents are a type of muscle relaxant. Neuromuscular blocking drugs used in anaesthesia are known as muscle relaxants or paralytics. By specifically blocking the neuromuscular junction they enable light anaesthesia to be used with adequate relaxation of the muscles of the abdomen and diaphragm. They also relax the vocal cords and allow the passage of a tracheal tube. Their action differs from the muscle relaxants used in musculoskeletal disorders that act on the spinal cord or brain. When action potentials cannot be transducted from the nerve to the muscle, loss of muscle tone and flaccid paralysis follows. You could not move your limbs because action potentials sent from your brain could not reach the muscles. ACh, a neurotransmitter used to send signals across a synapse, was inhibited by the paralytic. This means the signal could not cross the synapse and your muscles could not move. Sux is a depolarizing NMBD. Atracurium besilate, mivacurium, pancuronium bromide, rocuronium bromide and vecuronium bromide are examples of non-depolarizing NMBDs To understand how NMBDs work you can consider a lock and key mechanism analogy. If ACh is analogous to a key and ACh receptors are the keyhole, paralytic agents are a bit like stuffing chewing gum into the keyhole - they do not activate the unlocking mechanism but they take the spot of an ACh and prevent ACh from entering. A lock with chewing gum in it cannot operate, much like your muscles when under the effect of a paralytic. TLDR: Paralyzing agents are a type of muscle relaxant. Paralyzing agents prevent signals from your brain from reaching the muscles. They differ from relaxants used to treat sp@st!c disorders in that they act on the NMJ as opposed to the brain. You could not move because signals could not travel between your brain and your muscles due to the actions of paralytics

[@shanzaayub5824]

@Talpa that's sooooo soo soo detailed explanation. Thank you for your time and helping

[@shanzaayub5824]

@@benbookworm thank you very much it's very helpful

[@waelfadlallah8939]

Great details provided, i would like to add briefly that paralytics act at the neuromuscular junction so that acetylcholine can't reach the target. On the other hand, muscle relaxants such as baclofen act on the central nervous system so as to inhibit/reduce the propagation of signal to reach the skeletal muscles. You can summarized also by knowing the mechanism of action of certain drugs/toxins like botulinum toxin and curare which act peripherally and benzodiazepine which act centrally.

[@Boohpoop]

Will this procedure solve all of my financial problems and make my children behave better??

[@morganschiller2288]

Yep a Cadwell system is around 30K needles sold separately

[@robsab20]

You would think anaesthetic practice in a New York university hospital would be more… modern? How are they still using Cisatracurium and Succinylcholine in 2023? Discussing compulsive relaxometry?

[@morganschiller2288]

For some folks Roc is contraindicated. There is nothing wrong with Sux. We have plenty of folks here in Ohio that use a mix of Roc and Sux. I wouldn’t be dumping on years the drugs have been around. Inhalation agents and opiates have been around for a long time. Of course they are still used.

[@rm-dc6tx]

Is the IV succinocholine a triggering agent for Malignant Hypothermia or just the gas?

[@MaxFeinsteinMD]

Yes both succinylcholine (whether IV of IM) and volatile gas

[@etaoinwu]

nice video as always

[@RealEngineer]

Had multiple knee surgeries. And I made it a game to see how long I could stay awake while they read out the dosage 😂 1.0 - “I am still here” 2.2 - “Yea, nothing” … - “oh we are done?”

[@JrNelson-w4o]

I had to have hemorrhoidectomy and everybody in the operating room was so very nice and the Anesthesiologist he ask me if he could pray for me and I thought that was nice of him and it helped me to rest and I was up most of the night before so when they put the oxygen mask on I fall right to sleep I’m a minute?

[@smariec2021ify]

Dr. Max, Can you do a video on how electrodes on a patient’s head, that Anesthesiologist use, can tell if a patient is making memories? Because I have anesthesia awareness during surgical procedures, that is now used on me, but I’m wondering how does that work? Thank you for the videos that you post, and your response in advance! 9:12

[@jeffdo9195]

Why doesn't the heart stop when you paralyze the body?

[@ronshlomi582]

It's controlled by a completely disconnected set of muscles. Skeletal muscles (connected to bone) are very different from cardiac muscle in the heart. The heart is also controlled autonomically by the brain stem.

[@davidcottee2808]

@@ronshlomi582 It can stop if you can't ventilate 🥵

[@ronshlomi582]

@@davidcottee2808 Yeah, but it doesn't stop directly as a result of the paralytics.

[@davidcottee2808]

@@ronshlomi582 It can with a second dose of suxamethonium.

[@David-d2g3y]

Now would spinal fusion surgery be 1 that you wouldn't want the patient to be able to move

[@hannahkoeczko9782]

Brilliant 👏

[@thomashenden71]

It is somewhat hilarious that the device to determine twitch is called "Twitchview". 😄

[@privacyvalued4134]

4:12 A device with a button called "Tetanus." Hmm...

[@davidcottee2808]

You don't want to press that one while you're awake!

[@paulpoppenfuse7071]

Love ❤️

[@astrostar4181]

Thyroidectomy probably qualify paralyzation throughout surgery.

[@teamqueasy]

no

[@danielledinenno8714]

Sounds like all for my gallbladder to be removed

[@chrissieburke727]

U should make it videos a bit more dummied down for some of us watchers

[@MrBaskevin]

I wonder if you have been "under," your self?

[@ChrisPBacon-ok7ir]

Kidney beans ... lol

[@ColaTai]

Yo gib me some