Expert: Ronald Levy, M.D. - 12/14/2009

Question
QUESTION: I read your response on 12/3 to "anesthesia paralysis can't breathe" with interest since it relates to my own upcoming surgery. It's great that you include your personal experience with midazolam and amnesia; hearing this from an anesthesiologist means a lot.  I'm having full/total tummy tuck and this involves about 2 hours of  GA (previous spinal makes a spinal a bad option.  I'm in great health after the weight loss several years ago, I'm a low anesthesia risk and not really too concerned about the GA.  I work as a hospital pharmacist and pretty much trust the anesthesia/surgery team, my only issue is that I would like to avoid midazolam because of a previous bad experience with it during 2 endo procedures.  For the EGD, the amnesia persisted for a long time; the GI doc said that she probably pushed too much too fast and that a fair number of patients report the same thing. My experience with midazolam caused me to skip the drugs for the colonosopy; not my best decision...For my abdominoplasty, I can just see myself being awake and aware while being paralyzed and I realize that consenting to midazolam should blot this memory out somewhat.  My question is: before administeringa paralytic, couldn't they just give a sleep dose of propofol and wait until it took effect? (asleep = no memories, or am I oversimplifying this?).  I would appreciate your comments.  And please don't think that I'm in any way criticizing how anesthesia is administered (some of the comments that I have read suggest that amnesics are overused to cover sloppy technique, I don't believe that).  My wife (a dentist) says I'm crazy,  they use midazolam for almost all oral surgery without issue)....My PCP had the same problem with midazolam that I had (worse) and he tells all of his colonoscopy patients to pay extra for propofol if they can afford it.  Thanks.


ANSWER: Propofol also has amnestic properties (as do the inhaled anesthetics) so if you are trying to avoid all amnesia, this won't help. Versed is a stronger amnestic but the others work as well. In general we do wait for the anesthetic to take full effect before giving the paralytic. the only time we don't is if the patient is a high risk for aspiration and in those cases we sometimes cut it close. Generally people don't have the "paralyzed but awake" problems on induction but rather intraop or (most commonly) right before waking up. This is where the Versed is most useful (aside from its anxiolytic properties preop).

Ronald Levy, MD
Professor of Anesthesiology
UTMB-Galveston

---------- FOLLOW-UP ----------

QUESTION: sorry to bother you

Answer
It was not a bother. Since your followup question was just a comment and not a question, the only response option I could give was "This is a rude question/there is no question". Otherwise I get messages from AllExperts that I didn't answer a question. They should not put those two possible responses together (for obvious reasons).