Contents of the Anesthesiologist's Medication Cart in the Operating Room 

Glad you enjoyed! There are controlled substances that weren't covered in this video which we commonly use, but I think they're also medications you'd learn a lot about as a pharmacy student (eg. fentanyl, hydromorphone, remifentanyl, etc). Thanks for watching!

I agree! The focus on pharmacology is one of the (many) appealing aspects of anesthesiology to me.

How do they teach doctors to deliver bad news to a patient or their family? I am asking because I would imagine that doctors are not allowed to lie to a patient and they should not be giving false hope to a patient.

@@MaxFeinsteinMD Two questions. Do you beleive in allowing CRNA to take over the jobs of MD anesthesiologist? What is your opinion on CRNA?

@@davidsoto4394 Where I went to medical school, we received lectures and had practice sessions with paid actors on delivering bad news. You are 100% right that doctors should not lie to patients.

@@davidsoto4394 I think the best scenario is CRNAs and MDs working together to provide anesthetic care, not one overtaking another. I think CRNAs have an important role in helping care for patients, which is distinct from the role that physicians play.

Depends on the state. The anesthesiologist might only be there for the beginning and end of the surgery. Or there might be no doctor at all. It could be a nurse anesthetist, which I would promptly bang if you ever get a chance because they r LOADED

Thank you! I'm glad you enjoyed and got a peak into what we do.

Glad you enjoyed the video!

There is definitely a lot of responsibility when caring for someone under anesthesia. I hope everything goes well for you during your surgery!

@@MaxFeinsteinMD thank you!!!

You're welcome!

​@MaxFeinsteinMD you make my pre-surgery anxiety only a quarter of what it was! Much respect for anesthesiologists

Thanks for watching Steve! Glad you found it helpful and will let Dr. Fagelman know.

Great mnemonic, I use this often!

Thanks again Vicky! I wish I could take credit for the color coding. That is one of many standardized strategies to reduce medication error, and I’m very glad that’s routine practice.

Thanks so much!

Nice, I'm sure that's an interesting and fulfilling career, too!

@@MaxFeinsteinMD Do you beleive that premedical students should be taught by physicians and not by scientist and researchers because I beleive that doing this would make premedical education better and more clinicly relevant?

Dude Anesthesiologist and Radiology is like 3 million miles apart, why would you do that...? hope Ultrasound, CT, MRI and PET's are compensating for the fun you could have had learning what you loved being an "anesthesiologist"

Yes and no. As a physician in an academic setting who knows a ton about my field, I don’t really remember that much about many of the basic sciences or have kept up enough to discuss it in detail. I had a very science heavy undergrad so I came in to medschool solid on many of the basic sciences but medschool is just so much information that some of my undergrad courses were summarized in one single slide. So.. I don’t think practicing physicians are really equipped to go over the basic sciences in that level of detail. But yes, I do agree with you that the curriculum should be heavily guided by clinical practice. I remember in my medical school we spent 2 weeks on mycology while we spent 3 weeks on the physiology, pharmacology, pathology, histology of the renal system. As a practicing physician, my knowledge about mycology makes up around 0.05% of my practice while the renal is pretty important.

@@666Kudos Radiologist have alot of freedom and independence. I didn't want to work in the OR most of the day with a pain in the ass surgeon .

Wisdom teeth was my first time under anesthesia

For optometry school?? In case someone jabs their eyes to death or what??...

@@rjyeezy76 RSFA, rapid sequence fluorescein angiography. Requires injection of a 5 cc bolus of sodium fluorescein. Rarely induces anaphylaxis. Usually patient just vomits.

Glad you enjoyed the video! Hope to see you in the OR one day

Damn why have you had so many surgeries?

I’ve had a lot of surgeries and GI procedures under MAC or general anesthesia. Learning about the meds used due8mg anesthesia is interring

Hi Aaron, great question. We tend to prefer rocuronium at my hospital, I'm assuming partly because it's one of two non-depolarizing paralytics that has a direct reversal agent (sugammadex aka Bridion). The other reversible paralytic is vecuronium which you mentioned. Vecuronium and pancuronium both cause changes in hemodynamics where as rocuronium does to a lesser extent, which is probably why it's used more. Mivacurium, atricurium and cisatracurium are in a different class of paralytics and neither have reversal agents. I believe they have higher incidence of histamine-related side effects like hypotension. I've only used cisatracurium for kidney transplants since their metabolism is completely independent of the kidney. Hope that helps!

at the hospital where I worked for a little bit, all controlled substances were stored in a Pyxis locking medication safe which would only open one medication drawer at a time for controlled substances. at the start of each shift, the charge nurse and a pharmacist would download records of which meds, including controlled substances, were used on the previous shift, the number of dosing vials // pre-filled syringes that should be remaining, as well as if any meds needed to be restocked. Our department also had at least 1 RSI drug box in a separate safe that could only be unlocked by the charge nurse during emergencies such as status epilepticus or code blue events. Any time we had to waste controlled substances, a second nurse // pa // doctor // dentist // pharmacist would sign off as a witness of the medication wasted. Beyond that, there were security cameras, audible, and silent alarm systems to prevent theft. Unfortunately, if you made a typo on the quantity of controlled substances remaining, your account would be locked and you needed to call the pharmacy and security to unlock it to get out any other medications from the safe, regardless of whether they were or were not controlled substances, meaning you could accidentally get locked out and not be able to get meds people needed in a hurry. This was what I worked with about 10 years ago, keeping in mind that systems get upgrades and changes over time.

Yes, I've had it once before a procedure and can confirm it helps considerably with pre-procedure jitters!

@@MaxFeinsteinMD that’s good to know! I’m having hiatus hernia and fundopliction (probably not spelled correctly) in about 10 days. I’ve had plenty of surgeries but this one has me nervous even now. Btw, don’t know why I never thought you guys had a med cart in the or! Guess I just had other stuff going on.

Thanks Felipe, I appreciate the kind words. I *love* anesthesia and would be happy to answer any questions about picking it as a specialty! For what it's worth, I was considering internal medicine and emergency medicine prior to anesthesiology.

@@MaxFeinsteinMD Being from Brazil, things here are quite different when it comes to specialty choosing (EM is basically non existent here, the field is 5 or 10 yo). In the end I'm pretty sure anesthesia is where I'm going, just wish we had the same program dynamic and cool stuff you have in the US. I'd very interested in seeing more about Mount Sinai program, which is what you channel is all about. Keep up the good work!

@@MaxFeinsteinMD I am not in medical school but I find surgery and anesthesiology to be interesting. Is it possible for someone with Cerebralpalsy to attend medical school in the future and after completing all required traning and testing can someone with cerebralpalsy become an anesthesiologist in the future?

@@MaxFeinsteinMD Excellent video.

@@davidsoto4394 Hi David, good question. I think it depends on the level, if any, of physical manifestations of CP that might limit the ability to do certain physical tasks. When I was filling out paperwork to apply for or start medical school, I vaguely recall some documentation I had to sign indicating that I would be physically able to do some physically demanding tasks that were only loosely described. Stuff like CPR, having reasonable visual acuity to see monitors/paperwork/computer screen etc. I wish I could find that form. Anyways, I think this is a great question to ask a medical school admissions dean (even if you aren't ready to apply) to get a more insightful answer.

Yes it’s a very effective medication!

Same here! I had it during a nasty trip to the ER--saved me from so much pain that day. God bless!

You pay very close attention to detail! The stock image I grabbed from Google shows 1:1000 (Dr. Fagelmen didn't mention the specific dilution) but what we have in the carts is 1:10,000. Thanks for subscribing!

#1) I want to say thank you for replying to comments etc. #2) i have a question... I REALLY want to be a anesthesiologist. It has been my dream for ever. So i guess the question is, how and where did you start? What did you get a bachelors degree in? What kind of study time did you put in? Did you work while going to school? How old were you when you made this decision? Is there anything you wish you would have done differently? Did you have any field experience prior to going into this career? What steeping stones did you take ? It would be awesome if you could make a video talking about how you got to where u are now. Much respect. Like i said iv never had a chance to talk with someone about this and I’m sure in not the only one curious. Thanks man, I appreciate you.

Just watched the MH video so I found the answer to my question. Cheers!

Thank you!

Hi Audy, thanks for watching. We don't use ranitidine or sodium metamizole as far as I'm aware. I don't know why those wouldn't be on formulary or part of our daily practice - I'll see if I can find out!

Ranitidine (Zantac) is administered orally as an antacid.

It differs on a per-country and per-hospital basis.

Hi again Sherry,! You're right that propofol is used very commonly. In some hospitals, there's a special locked cart that required a code/fingerprint to open (this is called a Pyxis machine) which stores controlled medications like propofol. In my hospital, we order it ahead of time from a special pharmacist near the OR. If cases go longer than planned, we can always get more (during the case) from the pharmacist, although that might require someone else to physically get the medication since we're in the OR with our patient the whole time they're under anesthesia. We base our medication dosing (ie. when to push more meds) with clinical goals, like keeping a certain heart rate, blood pressure, or brain-wave reading (EEG) that indicates the extent to which someone is anesthetized. Hope that helps!

@@MaxFeinsteinMD thank you.Have a great weekend!!"

Yes, we have sugammadex nearby but not stocked in every cart. We typically use neostigmine for reversal.

In low doses, it can be a pretty effective anti-emetic

You also give it to patients who are freaking out and at risk to themselves or others. May not be comforting to know it's there as a patient, which may be why it wasn't discussed.

Post-operative delirium and also post-op nausea/vomiting prevention.

Hi there, I would make sure the patient got decadron at the beginning of the case (assuming no contraindications) and would also tailor my anesthetic plan to include propofol, if appropriate, as it has antiemetic properties.

We also use Haldol at my institution if no contraindications.

Thank you! We have several separate MH carts strategically located in our OR clusters.

I love you mentioned this, MH isn't brought up enough. I have it a long family history of it. Alot of people also have no idea what it is. When I say I have it most people ask what it is. Takes so long to explain.

@mrquarters1 You may find that answer in the OR notes from your surgery, of which a copy would be in your medical records. Or, if you have it, look at the itemized bill from the transplant surgery. Not sure this doc could tell you what was used on you 25-30 yrs ago. Good luck!🍀

Small vials, but highly concentrated

Most likely midazolam

It's really hospital-dependent and probably just comes down to cost at the end of the day. It used to be that sugammadex was more expensive than neostigmine, but I believe both drugs have had considerable price adjustments in recent years. Different hospitals are able to negotiate different prices with drug distributors, so it really just depends on specific circumstances. One other consideration is that sugammadex can theoretically render oral contraceptives ineffective for up to a week, so it's not ideal for use in elective surgery on a woman of reproductive age on OCPs.

@@MaxFeinsteinMD Thank you for the information! Please keep the videos coming for the budding anesthesiologists!

Hi there, these are great questions: 1- Yes I have, I was a young child and I'm pretty certain a gas anesthetic was used, probably sevoflurane because it has the least unpleasant smell compared to others. 2- The masks tend to have a plastic smell that itself is a little odd, maybe even unpleasant. It's possible that's what you were smelling. There's also a small chance there was still a small amount of anesthetic gas still in the circuit and you could have inhaled a tiny bit of it, but I think that's less likely. My bet is that it was probably just oxygen and a strong plastic smell. 3- Yes, occasionally I do mix gas and IV anesthetics. There are some surgeries that essentially require IV anesthesia with remifentanyl+propofol in order to keep a patient completely still without actually administering paralytics (spine surgery, brain surgery). I also prefer propofol for patients who have higher risk of nausea/vomiting because it can help prevent it. Otherwise anesthetic gas is usually a fair option for a lot of surgeries that require general anesthesia.

I’ve seen various methods of handling sharps being taught. I don’t know of one that’s been demonstrated to be safer than another- a lot of it seems to be personal preference, or what a person learned from the person who taught them.

Sort of guessing here, but I think MDI is just easier to open / administer in the OR, especially when bronchospasm is suspected and we have to do multiple interventions very quickly. We don’t stock nebs in the cart, I’m assuming for that reason. I’ll ask an attending, I’m curious too.

Not a doctor, but I’m assuming it’s for speed, I’d like to know the answer officially thought

Sorry, I know it can be nauseating to look at this stuff!

Yes, fentanyl or any other narcotics we use like dilaudid.

Thank you!

If someone is very disinhibited when they wake up, haldol can be helpful. But also it can help control nausea and vomiting, so I occasionally use it for that indication, too.

@@MaxFeinsteinMD thank you!

I probably wouldn't change anything about my medication types or dosing, but I would take more time as I prepare the patient who smokes to emerge from surgery. That's someone who I have more concerns about their ability to breath without any problems as the anesthesia wears off and I remove the breathing tube. Smokers are more susceptible to issues like bronchospasm, which is where the lungs kind of freeze up temporarily in a way that effectively stops breathing altogether. I've seen that once in a patient (who happened to be a smoker) and was able to treat it with epinephrine through the IV. Anyways, smokers' lungs are just more sensitive/delicate during surgery so I have to be even more on guard for issues that can arise.

@@MaxFeinsteinMD i enjoyed your explanation

The only reason I can think of to push a full 1mg of epi under any circumstance is cardiac arrest. Even for an allergic reaction, I would only dose 100mcg (which is 10% of 1mg) at a time. The only place you'd probably see people pushing 1mg epi for conditions ranging from arthritis to sneezing is Grey's Anatomy lol.

@@MaxFeinsteinMD haha I don’t doubt that they haven’t in one of their episodes! So if 1mg of epi is pushed with 80mcg of Clonidine then would the purpose of that combination given be that a patient is hypertensive and going into cardiac arrest or that a patient went into cardiac arrest and it caused hypertension?

They are refrigerated and then pulled out of the fridge when the carts are stocked.

No particular reason for using gloves in this video, other than to just keep everything extra clean since Dr. Fagelman was handling quite a few vials of medication that will be used for many other patients.

It takes lots of repetition to learn the pharm!

While it's true that a lot can potentially go wrong, there are many precautions taken to minimize risk in the OR!

@@MaxFeinsteinMD yeah they have to less or no complications is better. And the skill of the surgeon and other or staff but more weighs on the surgeon and you guys .plus the patients overall health

Ciao!

Hi Lindsay, an anesthesiologist is someone who went to medical school and became a physician, then later did a 4-year residency to specialize in anesthesiology. A CRNA is someone who went to nursing school to become a nurse, worked in an ICU for at least several years, then later did an additional ~2 years of training in anesthesiology. In practical terms, CRNAs work under the medical direction or supervision of an attending anesthesiology. It's often the case that there will be 4 operating rooms that each have a CRNA there the whole time, and then 1 MD who floats between the rooms. Hope that helps!

@@MaxFeinsteinMD From AANA it seems like CRNAs only need 1 year of ICU nursing experience.

@@nikhil4316 that is the minimum required although the average is 3 years

@@MaxFeinsteinMDMost CRNA programs are 3 years in length with it being 36 months of non-stop training.

Essentially the same for any premed path -- biology, biomedical sciences, neuroscience, stuff like that!

Hey that's awesome! I actually made a video where I include advice for highschoolers who are interested in anesthesiology. That video is called "Become an Anesthesiologist - Career Advice from an Anesthesia Resident" if you want to check that out. Let me know if you have any other questions. Thanks for watching, future Dr. Gesch!

Most medications I use have recommended weight-based dosing, however everyone's body responds differently so I always consider changing doses up or down depending on how much or how little effect I need (eg. medications to lower blood pressure). Great questions. Hope that helps!

@@MaxFeinsteinMD what book would you recommend someone read about anesthesia? Specifically, leaning about how reading a patients vitals on machines dictates at what times during the procedure you adjust meds?

Hey sorry for late reply. There’s a good book for starting to understand anesthesia, and it’s called Anesthesia Made East by Jeff Steiner. Hope that helps!

No in-OR Pyxis at my hospital, but we do have them in the PACUs. We get our controlled medications from the OR pharmacists.

Max Feinstein, MD Ok thanks for the info!

I'm not very familiar with careers paths for nursing, sorry!

@@MaxFeinsteinMD oh ok that’s fine

BSN nurses can make good money while only working 3 shifts of 12 hours. Average salary of a BSN RN is around 70-80k w/ experience. Graduate level nurses get paid more depending on the speciality. Hope that helps.

@@passion5554 That’s for the Info! I need to update the post because I’m going to join the Marines!!

The vast majority of everything in the cart is standby just in case it's needed. We have so many different drugs because they accomplish lots of different effects that may be needed during surgery.

@@MaxFeinsteinMD makes sense cause you never know what may happen and you have to be on the ready the whole time

Either when patients wake up very delirious, or as an alternative medication for nausea control.

Intuitively it would seem like that, but the reality is that the knowledge base and clinical expertise is actually quite different. A pharmacist wouldn’t be able to do any of the procedures I do, nor would I know much about how to dose meds outside the realm of anesthesia like a pharmacist does, for example.

@@MaxFeinsteinMD ohhhhh thank you so much 😊

Hello Michael. General Anesthesia is quite safe. I would not worry. Increased risk of having an adverse reaction is more commonly seen in patients who are either elderly and/or have a serious pre-existing health problem. The doctor will administer a medication beforehand to help you relax. And when the procedure is complete you wont recall any of it.

@@rjyeezy76 well I don't want anything. Before surgery. And I have asthma High blood pressure high cholesterol enlarged prostate

@@rjyeezy76 I don't want to be so drugged up I don't know what is going on before the surgery even starts. That's important to me

@@rjyeezy76 that s another concern memory loss of cognitive function. I do have a life and I don't some surgery to make it worse for me .I'm fairly active I work at Dunkin doughnuts here in Daytona beach Florida and I want to get back to what I was doing before surgery I'm hoping he can do robotic surgery there are loops of small intestine on the left side in the scrotum and right is higher up but still at top of scrotum

If your blood pressure is already being managed with prescription medication it won't be a problem. The same goes for asthma. For example, my father has athsma and had had three surgical procedures over the last five years- No problems.

Looking forward to when we can have people shadowing again!

Fentanyl/ketamine/reminfentanyl etc all the controlled medications plus propofol are all kept at the pharmacy

@@MaxFeinsteinMD Why it could be used for emergencies during operations

@@vacationhike6338 We always pick up controlled medications from the pharmacy before we start a case, so we'll have whatever we need on us during the surgery!