Guide This is why surgery will DESTROY YOUR BRAIN if you don't follow this anesthesia guide

Acromegaly_Chad

Acromegaly_Chad

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TLDR: See at the bottom

This thread is an absolute premiere in the PSL sphere because nobody has ever done anything like this before. This is the first complete guide on why blood pressure in anesthesia is so important and why it can destroy YOUR brain. Anesthesia is often mentioned in the connection with postoperative cognitive dysfunction and memory loss. However, a deeper look into the subject reveals that there is A LOT that can be done to reduce these effects. From my understanding, the 2 most important factors with regard to anesthesia that are often being overlooked are blood pressure and the use of opioids.

As some of you know I've recently been on the brink of collapsing as a result of badly performed anesthesia. I feared that I got permanent brain and cardiac damage from oxygen deficiency and even worse. Probably nothing happened, but I'm still in shock and am not sure if I will ever recover psychologically from it. Therefore, let's dive right into the matter: Why you need to watch out when you're getting maxillofacial surgery: risks, that nobody talks about.


Hypotensive anesthesia is considered a suitable anesthetic technique for patients undergoing [...] major maxillofacial operations (Barak et al., 2015). All the maxillofacial surgeries that are being discussed on Looksmax (Lefort 1-3, BSSO, Genioplasty, Chin Wing, wisdom teeth extraction, jaw implants, orbital box osteotomy and more) are being performed under hypotensive anesthesia. Surgical procedures on the head and neck have a propensity to bleed profoundly because the region's blood supply is rich (Barak et al., 2015).
Reducing blood pressure and thus perfusion of the tissue around the surgical area results in (1) less blood loss (2) improved view of the surgical field and (3) allogeneic blood transfusion becoming redundant.

However, Barak et al. (2015) note that the use of hypotensive anesthesia is associated with the risk of reduced perfusion to important organs and tissues, mainly the brain, heart, and kidneys. The majority of studies, with the exception of a few outliers, demonstrate that hypotension during a variety of noncardiac surgeries is associated with various unfavorable outcomes, including increased mortality, longer hospitalization, all-cause morbidity, acute kidney injury, myocardial injury, postoperative congestive heart failure, stroke, postoperative cognitive decline, postoperative delirium, poor liver and kidney graft function, and postesophagectomy anastomotic leakage (Meng et al., 2018).

In hypotensive anesthesia, the patient's baseline means arterial pressure (MAP) is reduced by 30% (Barak et al., 2015). Consequently, the systolic blood pressure values are about 80–90 mm Hg and the MAP (Mean arterial pressure) is reduced to 50–65 mm Hg.

MAP is calculated as [Systolic Blood Pressure + 2(Diastolic Blood Pressure)]/3

MAP is an important measure for the blood flow to your organs and therefore a crucial aspect of safe hypotensive anesthesia.

But what we have learned so far is that (1) maxillofacial surgery requires hypotensive anesthesia and (2) that in turn is associated with several serious risks.

So far, my research has resulted in 2 different strategies to deal with this issue:

1) Get minimally invasive maxillofacial surgery or have a surgeon willing to perform surgery with normotensive (normal blood pressure) anesthesia on you. The less invasive the surgery i.e. the less tissue is being cut and scars produced, the less bleeding will occur and consequently the higher the threshold for tolerable blood pressure. I'm in contact with Dr. Alfaros clinic to get a view into their anesthesia protocols because maybe the minimally invasive approach allows for higher blood pressure and all the advantages accompanied by it (faster recovery, no memory loss, no delirium).

2) IF you are about to get hypotensive anesthesia, consider the following:


330px Cerebrovascular autoregulation


The abscissa (horizontal line) shows MAP blood pressure while the ordinate shows blood flow to the brain. The grey area represents the range of MAP that is within the cerebral autoregulation, meaning where the brain can regulate blood supply nearly independently from blood pressure.

- MAP must not be lower than 50 mm Hg during surgery, ideally, it must not be lower than 60 mm Hg. Feel free to talk to your anesthesiologist about this very openly and directly, because there are many retarded anesthesiologists out there who go to the limit and go as low as 50 mm Hg when the incompetent maxfac tells them to do so. You will eventually notice that at the very latest when you awake after surgery as a retard.

If this is still not possible, consider the following: a person with an arterial partial pressure of carbon dioxide (PaCO2) of 40 mmHg (normal range of 38–42 mmHg) and a Cerebral Blood Flow (CBF) of 50 ml per 100g per min. If the PaCO2 dips to 30 mmHg, this represents a 10 mmHg decrease from the initial value of PaCO2. Consequently, the CBF decreases by 1ml per 100g per min for each 1mmHg decrease in PaCO2, resulting in a new CBF of 40ml per 100g of brain tissue per minute.

- Lower levels of PaCO2 are associated with increased tolerance for hypotensive blood pressure (pushing the 50 mm Hg barrier) and vice versa. So tell your anesthesiologist to make the fuck sure to get the PaCO2 levels as low as possible if hypotensive blood pressure is indeed required. Anesthesiologists are (in my opinion) not sensitized enough to the importance of this. Many are willing to accept cognitive decline in their patients just for the sake of a more comfortable/standardized anesthesia.

Furthermore, the MAP baseline may vary from person to person. Define your baseline by accurately measuring your blood pressure several times before surgery and on the day of surgery. If you are a hypertensive person (high blood pressure) the grey area in the graph above shifts to the left or the orange line to the right. You may get brain damage at as high as MAP 60 mm Hg. Tell your anesthesiologist your blood pressure levels therefore in advance so that he knows.

Concerning opioids:

In anesthesia, the use of painkillers such as opioids is of crucial importance to manage perioperative pain and reduce the amount of propofol to keep you asleep (good pain management allows to reduce propofol doses to as low as 4mg/kg/h while bad management can require doses as high as 12mg/kg/h). However, the use of opioids can cause fatigue, breath depression and apnea, as well as prolonged brain fog and synaptic inflammation.

The gold standard for pain management in maxillofacial surgery anesthesia is a multimodal analgesia approach (paracetamol, nonsteroidal antiinflammatory drugs, corticosteroids, lidocaine and other long-acting local anesthetics, ketamine, magnesium sulfate and dexmedetomidine, among others) as well as ultrasound-guided bilateral suprazygomatic maxillary nerve block with ropivacaine. With regards to multimodal analgesia Alfaro et al. (2022) note that "Our recommendation in orthognathic surgery therefore is to administer multimodal analgesia with non-opioid agents such as N-methyl-d-aspartate antagonists, local anesthetics and alpha-2-agonists, together with low-opioid anesthesia and monitoring of nociception. These additive and/or synergic combinations of analgesics and anesthetics are effective and safe in improving the postoperative outcomes of patients subjected to orthognathic surgery globally."

What does this mean for you? Again, ask your clinic which painkillers they use, and decide based on that for/against the clinic. They play a crucial role in the post-surgical process and how well you recover.

At the end of the day, considering these guidelines on blood pressure and opioids will allow you to have much more surgery with fewer side effects.

TLDR


The ideal for anesthesia in maxillofacial surgery

- Short surgery time
- normotensive (normal blood pressure)
- no hypotension (no MAP blood pressure below 65 mm Hg)
- minimally invasive approach to minimize bleeding and avoid allogeneic blood transfusion
- IF you have to get hypotensive anesthesia, consider:
- very low levels of PaCO2
- your baseline blood pressure
- Multimodal analgesia approach is superior to the use of opioids as painkillers


Sources:

Barak, M., Yoav, L., & Abu el-Naaj, I. (2015). Hypotensive anesthesia versus normotensive anesthesia during major maxillofacial surgery: a review of the literature. TheScientificWorldJournal, 2015, 480728. https://doi.org/10.1155/2015/480728

Meng, L., Yu, W., Wang, T., Zhang, L., Heerdt, P. M., & Gelb, A. W. (2018). Blood Pressure Targets in Perioperative Care. Hypertension (Dallas, Tex. : 1979), 72(4), 806–817. https://doi.org/10.1161/HYPERTENSIONAHA.118.11688

Molins-Ballabriga, G., Hernández-Alfaro, F., Giralt-Hernando, M., & Valls-Ontañón, A. (2022). Multimodal analgesia in orthognathic surgery. Journal Of Oral And Maxillofacial Anesthesia, 1. doi:10.21037/joma-22-1

Tagging some surgery niggas:

@RealSurgerymax @Sergio-OMS
 
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Bookmarked because I don't want to wake up as a retard.
 
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will a surgeon really change their operation procedures for an autist? theyll probably just think ur a pain in the ass and tell u to go somewhere else if u dont like the way they do their surgeries tbh
 
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brain already destroyed from years of inceldom and isolation
 
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good work
 
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Nice research but I don't know what to do with it. If I showed this to my surgeon I will prob. Be dropped as a patient.

I am pretty sure that medical professionals get courses when graduated to keep up with the newest researches (atleast is in my country).
Hope they learn stuff like this. Other then that you can't do anything and hope you will wake up fine after surgery.
 
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Nice research but I don't know what to do with it. If I showed this to my surgeon I will prob. Be dropped as a patient.

I am pretty sure that medical professionals get courses when graduated to keep up with the newest researches (atleast is in my country).
Hope they learn stuff like this. Other then that you can't do anything and hope you will wake up fine after surgery.
A kind of naive view IMO, you overestimate their willingness to try new techniques and methods. A lot of people in the area a very conservative and in case of anesthesiologists they would prefer a "stable retard".
 
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im taking 45mg a day phenelzine rn, do you suggest i stop or lower the dose before i have my rhinoplasty?
 
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do you expect me to show this shit to an actual anesthesiologist and tell that mf how to do his job cuz an incel on the internet told me so ? What the fuck is this post fr
 
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Designing an implant is too hard for me, and now I should do an anesthesiologist's job? What about no.
 
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this mf thinks he can outfinesse anestheologists :lul:
 
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do you expect me to show this shit to an actual anesthesiologist and tell that mf how to do his job cuz an incel on the internet told me so ? What the fuck is this post fr
mf with common sense
 
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I nearly required a blood transfusion during bimax, and the surgery itself went way over time. I'm performing better than ever in my STEM job now two years post op, although I attribute piracetam and similar nootropics to this performance increase.
 
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brain already destroyed from years of inceldom and isolation
Experienced first hand. As a rule of thumb for every year of rotting and inceldom expect half the time for acquired brain disorders to reverse. The non-exhaustive list includes brain fog, social autism, anhedonia, neuroticism, IQ drop, fatigue, the list really does go on. In my case the recovery time was 3 years for 6-7years of prolonged inceldom and social withdrawal.
 
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what's the risk of getting brain damage from surgery like bimax? i didn't see any statistics in your post.

if it's 1/1000 or something it is what is. I mean I've seen hundreds of bimax result posts from redditards and most of them got from incompetent surgeons none of them mentioned brain damage.
 
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what's the risk of getting brain damage from surgery like bimax? i didn't see any statistics in your post.

if it's 1/1000 or something it is what is. I mean I've seen hundreds of bimax result posts from redditards and most of them got from incompetent surgeons none of them mentioned brain damage.
local anesthesia should be even safer right?
 
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I nearly required a blood transfusion during bimax, and the surgery itself went way over time. I'm performing better than ever in my STEM job now two years post op, although I attribute piracetam and similar nootropics to this performance increase.
How long did your surgery take?
 
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do you expect me to show this shit to an actual anesthesiologist and tell that mf how to do his job cuz an incel on the internet told me so ? What the fuck is this post fr
Yes, it's pretty standard to have a quick talk with the anesthesiologist before surgery. And then you can ask him.

There is so some who stick to the above mentionned regime and some who don't. Avoid the latter.

That being said, anesthesia isn't a one way road. There's many different ways to perform anesthesia depending on the patient specific requirements.

So yes - if you tell you anesthesioligist that you can't endure BP below MAP 65, they will discuss and look for a way to maneuvre around that.
 
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I had 3 general anesthesia surgeries in period of 6 months. No cognitive problems noticed.
 
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I had 3 general anesthesia surgeries in period of 6 months. No cognitive problems noticed.
I had 6 in 7 months, I'm probably slightly retarded now
 
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dnr
I am going all natural no anesthesia for my hair transplant
 
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And that would be a net loss how exactly?
 
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TLDR: See at the bottom

This thread is an absolute premiere in the PSL sphere because nobody has ever done anything like this before. This is the first complete guide on why blood pressure in anesthesia is so important and why it can destroy YOUR brain. Anesthesia is often mentioned in the connection with postoperative cognitive dysfunction and memory loss. However, a deeper look into the subject reveals that there is A LOT that can be done to reduce these effects. From my understanding, the 2 most important factors with regard to anesthesia that are often being overlooked are blood pressure and the use of opioids.

As some of you know I've recently been on the brink of collapsing as a result of badly performed anesthesia. I feared that I got permanent brain and cardiac damage from oxygen deficiency and even worse. Probably nothing happened, but I'm still in shock and am not sure if I will ever recover psychologically from it. Therefore, let's dive right into the matter: Why you need to watch out when you're getting maxillofacial surgery: risks, that nobody talks about.


Hypotensive anesthesia is considered a suitable anesthetic technique for patients undergoing [...] major maxillofacial operations (Barak et al., 2015). All the maxillofacial surgeries that are being discussed on Looksmax (Lefort 1-3, BSSO, Genioplasty, Chin Wing, wisdom teeth extraction, jaw implants, orbital box osteotomy and more) are being performed under hypotensive anesthesia. Surgical procedures on the head and neck have a propensity to bleed profoundly because the region's blood supply is rich (Barak et al., 2015).
Reducing blood pressure and thus perfusion of the tissue around the surgical area results in (1) less blood loss (2) improved view of the surgical field and (3) allogeneic blood transfusion becoming redundant.

However, Barak et al. (2015) note that the use of hypotensive anesthesia is associated with the risk of reduced perfusion to important organs and tissues, mainly the brain, heart, and kidneys. The majority of studies, with the exception of a few outliers, demonstrate that hypotension during a variety of noncardiac surgeries is associated with various unfavorable outcomes, including increased mortality, longer hospitalization, all-cause morbidity, acute kidney injury, myocardial injury, postoperative congestive heart failure, stroke, postoperative cognitive decline, postoperative delirium, poor liver and kidney graft function, and postesophagectomy anastomotic leakage (Meng et al., 2018).

In hypotensive anesthesia, the patient's baseline means arterial pressure (MAP) is reduced by 30% (Barak et al., 2015). Consequently, the systolic blood pressure values are about 80–90 mm Hg and the MAP (Mean arterial pressure) is reduced to 50–65 mm Hg.

MAP is calculated as [Systolic Blood Pressure + 2(Diastolic Blood Pressure)]/3

MAP is an important measure for the blood flow to your organs and therefore a crucial aspect of safe hypotensive anesthesia.

But what we have learned so far is that (1) maxillofacial surgery requires hypotensive anesthesia and (2) that in turn is associated with several serious risks.

So far, my research has resulted in 2 different strategies to deal with this issue:

1) Get minimally invasive maxillofacial surgery or have a surgeon willing to perform surgery with normotensive (normal blood pressure) anesthesia on you. The less invasive the surgery i.e. the less tissue is being cut and scars produced, the less bleeding will occur and consequently the higher the threshold for tolerable blood pressure. I'm in contact with Dr. Alfaros clinic to get a view into their anesthesia protocols because maybe the minimally invasive approach allows for higher blood pressure and all the advantages accompanied by it (faster recovery, no memory loss, no delirium).

2) IF you are about to get hypotensive anesthesia, consider the following:


View attachment 1870635

The abscissa (horizontal line) shows MAP blood pressure while the ordinate shows blood flow to the brain. The grey area represents the range of MAP that is within the cerebral autoregulation, meaning where the brain can regulate blood supply nearly independently from blood pressure.

- MAP must not be lower than 50 mm Hg during surgery, ideally, it must not be lower than 60 mm Hg. Feel free to talk to your anesthesiologist about this very openly and directly, because there are many retarded anesthesiologists out there who go to the limit and go as low as 50 mm Hg when the incompetent maxfac tells them to do so. You will eventually notice that at the very latest when you awake after surgery as a retard.

If this is still not possible, consider the following: a person with an arterial partial pressure of carbon dioxide (PaCO2) of 40 mmHg (normal range of 38–42 mmHg) and a Cerebral Blood Flow (CBF) of 50 ml per 100g per min. If the PaCO2 dips to 30 mmHg, this represents a 10 mmHg decrease from the initial value of PaCO2. Consequently, the CBF decreases by 1ml per 100g per min for each 1mmHg decrease in PaCO2, resulting in a new CBF of 40ml per 100g of brain tissue per minute.

- Lower levels of PaCO2 are associated with increased tolerance for hypotensive blood pressure (pushing the 50 mm Hg barrier) and vice versa. So tell your anesthesiologist to make the fuck sure to get the PaCO2 levels as low as possible if hypotensive blood pressure is indeed required. Anesthesiologists are (in my opinion) not sensitized enough to the importance of this. Many are willing to accept cognitive decline in their patients just for the sake of a more comfortable/standardized anesthesia.

Furthermore, the MAP baseline may vary from person to person. Define your baseline by accurately measuring your blood pressure several times before surgery and on the day of surgery. If you are a hypertensive person (high blood pressure) the grey area in the graph above shifts to the left or the orange line to the right. You may get brain damage at as high as MAP 60 mm Hg. Tell your anesthesiologist your blood pressure levels therefore in advance so that he knows.

Concerning opioids:

In anesthesia, the use of painkillers such as opioids is of crucial importance to manage perioperative pain and reduce the amount of propofol to keep you asleep (good pain management allows to reduce propofol doses to as low as 4mg/kg/h while bad management can require doses as high as 12mg/kg/h). However, the use of opioids can cause fatigue, breath depression and apnea, as well as prolonged brain fog and synaptic inflammation.

The gold standard for pain management in maxillofacial surgery anesthesia is a multimodal analgesia approach (paracetamol, nonsteroidal antiinflammatory drugs, corticosteroids, lidocaine and other long-acting local anesthetics, ketamine, magnesium sulfate and dexmedetomidine, among others) as well as ultrasound-guided bilateral suprazygomatic maxillary nerve block with ropivacaine. With regards to multimodal analgesia Alfaro et al. (2022) note that "Our recommendation in orthognathic surgery therefore is to administer multimodal analgesia with non-opioid agents such as N-methyl-d-aspartate antagonists, local anesthetics and alpha-2-agonists, together with low-opioid anesthesia and monitoring of nociception. These additive and/or synergic combinations of analgesics and anesthetics are effective and safe in improving the postoperative outcomes of patients subjected to orthognathic surgery globally."

What does this mean for you? Again, ask your clinic which painkillers they use, and decide based on that for/against the clinic. They play a crucial role in the post-surgical process and how well you recover.

At the end of the day, considering these guidelines on blood pressure and opioids will allow you to have much more surgery with fewer side effects.

TLDR


The ideal for anesthesia in maxillofacial surgery

- Short surgery time
- normotensive (normal blood pressure)
- no hypotension (no MAP blood pressure below 65 mm Hg)
- minimally invasive approach to minimize bleeding and avoid allogeneic blood transfusion
- IF you have to get hypotensive anesthesia, consider:
- very low levels of PaCO2
- your baseline blood pressure
- Multimodal analgesia approach is superior to the use of opioids as painkillers


Sources:

Barak, M., Yoav, L., & Abu el-Naaj, I. (2015). Hypotensive anesthesia versus normotensive anesthesia during major maxillofacial surgery: a review of the literature. TheScientificWorldJournal, 2015, 480728. https://doi.org/10.1155/2015/480728

Meng, L., Yu, W., Wang, T., Zhang, L., Heerdt, P. M., & Gelb, A. W. (2018). Blood Pressure Targets in Perioperative Care. Hypertension (Dallas, Tex. : 1979), 72(4), 806–817. https://doi.org/10.1161/HYPERTENSIONAHA.118.11688

Molins-Ballabriga, G., Hernández-Alfaro, F., Giralt-Hernando, M., & Valls-Ontañón, A. (2022). Multimodal analgesia in orthognathic surgery. Journal Of Oral And Maxillofacial Anesthesia, 1. doi:10.21037/joma-22-1

Tagging some surgery niggas:

@RealSurgerymax @Sergio-OMS
This explains a fuck ton of shit about why anyone who ascends with surgery is "forever scarred from inceldom" or people like James sapphire got fucked over, great post brudda
 
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No problemo since my brain is already heavily damaged :feelsokman:
 
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yeah this is my primary concern with surgery. POCD is much more likely when you have preexisting brain damage. plenty ways to prevent it though since it comes from overactive microglia --> neuroinflammation, edavarone, berberine, resveratrol etc. and requesting certain anesthetics over others like IV dexmedetomidine over midazolam should be sufficient

retards trashing OP for heads up thread meanwhile in communities where people actually get surgery brain fog is a common complaint (rhino facebook groups)
 
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yeah this is my primary concern with surgery. POCD is much more likely when you have preexisting brain damage. plenty ways to prevent it though since it comes from overactive microglia --> neuroinflammation, edavarone, berberine, resveratrol etc. and requesting certain anesthetics over others like IV dexmedetomidine over midazolam should be sufficient

retards trashing OP for heads up thread meanwhile in communities where people actually get surgery brain fog is a common complaint (rhino facebook groups)
Yep this is all true. Not to mention reduction of overall surgical time.

Many other things can be done too: Take in special nutriants before surgery, split surgeries so that your time under anesthesia is never longer than 3 hours, and take plenty of time between the surgeries (2 years at least) to make a full recovery.


Although I have to admit that this time, my problems weren't anesthesia related but came from a misplaced neck bone.
 
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are you going to get mse? and do you think its worth for guys 22+ years of age?
 
I used to have a fear of Anaesthesia that I'd wake up a different person. Like I'd have all my past memories etc but it's no longer me, like I die then a new me wakes up and experiences the change.

Then I had General Anaesthesia aged 13 and woke up pissed off as if it was just 30 seconds ago the Dr stuck that mask on my face to put me to sleep lmao. I was out for an 1.5-2 hours, went on to ace all my grades and had no cognitive issues.
 
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if u are going to tell this to ur anesthiologist then i would recommend u tell them in a respectful manner and tell them that u trust them and just have some concerns.

if u go in like a autist and tell them how to do their job then i doubt they will listen to u.

if u are a real sigma lie to them and tell them ur also a doctor.
 
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split surgeries so that your time under anesthesia is never longer than 3 hours, and take plenty of time between the surgeries (2 years at least)
2 years?????!!!! wtf dude? is there any study showing frequency to anesthesia exposure
 
i‘m going to get sinusitis surgery soon, does this also apply to me?
 
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Thanks, I am planning bimax surgery, I've asked my surgeon (real beast in my country) if he uses hypotensia while operating his patients and he luckily said no. So I am relaxed now :lul:
 
>yeah yeah sure I'll keep it at 60 chief :D
>I'll fucking show that incel. how dare he tell me what to do. yeah 40 will be nice :sneaky:
 
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Thanks, I am planning bimax surgery, I've asked my surgeon (real beast in my country) if he uses hypotensia while operating his patients and he luckily said no. So I am relaxed now :lul:
Who is the surgeon?
 
Experienced first hand. As a rule of thumb for every year of rotting and inceldom expect half the time for acquired brain disorders to reverse. The non-exhaustive list includes brain fog, social autism, anhedonia, neuroticism, IQ drop, fatigue, the list really does go on. In my case the recovery time was 3 years for 6-7years of prolonged inceldom and social withdrawal.
Did you actually reverse everything? I’ve probaby spent 7 years as an incel now too, do you genuinely feel your brain has repaired itself?
 
Thread is true, fucked after surgery bruvs
 
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Anesthesiologists are highly trained, i doubt they would do something that is wrong and makes you into a retard. They'd be on the hook and potentially lose their license.
 
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TLDR: See at the bottom

This thread is an absolute premiere in the PSL sphere because nobody has ever done anything like this before. This is the first complete guide on why blood pressure in anesthesia is so important and why it can destroy YOUR brain. Anesthesia is often mentioned in the connection with postoperative cognitive dysfunction and memory loss. However, a deeper look into the subject reveals that there is A LOT that can be done to reduce these effects. From my understanding, the 2 most important factors with regard to anesthesia that are often being overlooked are blood pressure and the use of opioids.

As some of you know I've recently been on the brink of collapsing as a result of badly performed anesthesia. I feared that I got permanent brain and cardiac damage from oxygen deficiency and even worse. Probably nothing happened, but I'm still in shock and am not sure if I will ever recover psychologically from it. Therefore, let's dive right into the matter: Why you need to watch out when you're getting maxillofacial surgery: risks, that nobody talks about.


Hypotensive anesthesia is considered a suitable anesthetic technique for patients undergoing [...] major maxillofacial operations (Barak et al., 2015). All the maxillofacial surgeries that are being discussed on Looksmax (Lefort 1-3, BSSO, Genioplasty, Chin Wing, wisdom teeth extraction, jaw implants, orbital box osteotomy and more) are being performed under hypotensive anesthesia. Surgical procedures on the head and neck have a propensity to bleed profoundly because the region's blood supply is rich (Barak et al., 2015).
Reducing blood pressure and thus perfusion of the tissue around the surgical area results in (1) less blood loss (2) improved view of the surgical field and (3) allogeneic blood transfusion becoming redundant.

However, Barak et al. (2015) note that the use of hypotensive anesthesia is associated with the risk of reduced perfusion to important organs and tissues, mainly the brain, heart, and kidneys. The majority of studies, with the exception of a few outliers, demonstrate that hypotension during a variety of noncardiac surgeries is associated with various unfavorable outcomes, including increased mortality, longer hospitalization, all-cause morbidity, acute kidney injury, myocardial injury, postoperative congestive heart failure, stroke, postoperative cognitive decline, postoperative delirium, poor liver and kidney graft function, and postesophagectomy anastomotic leakage (Meng et al., 2018).

In hypotensive anesthesia, the patient's baseline means arterial pressure (MAP) is reduced by 30% (Barak et al., 2015). Consequently, the systolic blood pressure values are about 80–90 mm Hg and the MAP (Mean arterial pressure) is reduced to 50–65 mm Hg.

MAP is calculated as [Systolic Blood Pressure + 2(Diastolic Blood Pressure)]/3

MAP is an important measure for the blood flow to your organs and therefore a crucial aspect of safe hypotensive anesthesia.

But what we have learned so far is that (1) maxillofacial surgery requires hypotensive anesthesia and (2) that in turn is associated with several serious risks.

So far, my research has resulted in 2 different strategies to deal with this issue:

1) Get minimally invasive maxillofacial surgery or have a surgeon willing to perform surgery with normotensive (normal blood pressure) anesthesia on you. The less invasive the surgery i.e. the less tissue is being cut and scars produced, the less bleeding will occur and consequently the higher the threshold for tolerable blood pressure. I'm in contact with Dr. Alfaros clinic to get a view into their anesthesia protocols because maybe the minimally invasive approach allows for higher blood pressure and all the advantages accompanied by it (faster recovery, no memory loss, no delirium).

2) IF you are about to get hypotensive anesthesia, consider the following:


View attachment 1870635

The abscissa (horizontal line) shows MAP blood pressure while the ordinate shows blood flow to the brain. The grey area represents the range of MAP that is within the cerebral autoregulation, meaning where the brain can regulate blood supply nearly independently from blood pressure.

- MAP must not be lower than 50 mm Hg during surgery, ideally, it must not be lower than 60 mm Hg. Feel free to talk to your anesthesiologist about this very openly and directly, because there are many retarded anesthesiologists out there who go to the limit and go as low as 50 mm Hg when the incompetent maxfac tells them to do so. You will eventually notice that at the very latest when you awake after surgery as a retard.

If this is still not possible, consider the following: a person with an arterial partial pressure of carbon dioxide (PaCO2) of 40 mmHg (normal range of 38–42 mmHg) and a Cerebral Blood Flow (CBF) of 50 ml per 100g per min. If the PaCO2 dips to 30 mmHg, this represents a 10 mmHg decrease from the initial value of PaCO2. Consequently, the CBF decreases by 1ml per 100g per min for each 1mmHg decrease in PaCO2, resulting in a new CBF of 40ml per 100g of brain tissue per minute.

- Lower levels of PaCO2 are associated with increased tolerance for hypotensive blood pressure (pushing the 50 mm Hg barrier) and vice versa. So tell your anesthesiologist to make the fuck sure to get the PaCO2 levels as low as possible if hypotensive blood pressure is indeed required. Anesthesiologists are (in my opinion) not sensitized enough to the importance of this. Many are willing to accept cognitive decline in their patients just for the sake of a more comfortable/standardized anesthesia.

Furthermore, the MAP baseline may vary from person to person. Define your baseline by accurately measuring your blood pressure several times before surgery and on the day of surgery. If you are a hypertensive person (high blood pressure) the grey area in the graph above shifts to the left or the orange line to the right. You may get brain damage at as high as MAP 60 mm Hg. Tell your anesthesiologist your blood pressure levels therefore in advance so that he knows.

Concerning opioids:

In anesthesia, the use of painkillers such as opioids is of crucial importance to manage perioperative pain and reduce the amount of propofol to keep you asleep (good pain management allows to reduce propofol doses to as low as 4mg/kg/h while bad management can require doses as high as 12mg/kg/h). However, the use of opioids can cause fatigue, breath depression and apnea, as well as prolonged brain fog and synaptic inflammation.

The gold standard for pain management in maxillofacial surgery anesthesia is a multimodal analgesia approach (paracetamol, nonsteroidal antiinflammatory drugs, corticosteroids, lidocaine and other long-acting local anesthetics, ketamine, magnesium sulfate and dexmedetomidine, among others) as well as ultrasound-guided bilateral suprazygomatic maxillary nerve block with ropivacaine. With regards to multimodal analgesia Alfaro et al. (2022) note that "Our recommendation in orthognathic surgery therefore is to administer multimodal analgesia with non-opioid agents such as N-methyl-d-aspartate antagonists, local anesthetics and alpha-2-agonists, together with low-opioid anesthesia and monitoring of nociception. These additive and/or synergic combinations of analgesics and anesthetics are effective and safe in improving the postoperative outcomes of patients subjected to orthognathic surgery globally."

What does this mean for you? Again, ask your clinic which painkillers they use, and decide based on that for/against the clinic. They play a crucial role in the post-surgical process and how well you recover.

At the end of the day, considering these guidelines on blood pressure and opioids will allow you to have much more surgery with fewer side effects.

TLDR


The ideal for anesthesia in maxillofacial surgery

- Short surgery time
- normotensive (normal blood pressure)
- no hypotension (no MAP blood pressure below 65 mm Hg)
- minimally invasive approach to minimize bleeding and avoid allogeneic blood transfusion
- IF you have to get hypotensive anesthesia, consider:
- very low levels of PaCO2
- your baseline blood pressure
- Multimodal analgesia approach is superior to the use of opioids as painkillers


Sources:

Barak, M., Yoav, L., & Abu el-Naaj, I. (2015). Hypotensive anesthesia versus normotensive anesthesia during major maxillofacial surgery: a review of the literature. TheScientificWorldJournal, 2015, 480728. https://doi.org/10.1155/2015/480728

Meng, L., Yu, W., Wang, T., Zhang, L., Heerdt, P. M., & Gelb, A. W. (2018). Blood Pressure Targets in Perioperative Care. Hypertension (Dallas, Tex. : 1979), 72(4), 806–817. https://doi.org/10.1161/HYPERTENSIONAHA.118.11688

Molins-Ballabriga, G., Hernández-Alfaro, F., Giralt-Hernando, M., & Valls-Ontañón, A. (2022). Multimodal analgesia in orthognathic surgery. Journal Of Oral And Maxillofacial Anesthesia, 1. doi:10.21037/joma-22-1

Tagging some surgery niggas:

@RealSurgerymax @Sergio-OMS
Bookmarked
 
Have been feeling like shit since my surgery ngl
 
I heard if they say they are going to anesthetize you with fentanyl you're supposed to tell them to use morphine, because it has less side effects but costs more.
 
  • Woah
Reactions: Acromegaly_Chad

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