even paranoids have enemies: The ‘Establishment’ Strikes Back at Goldilocks anesthesia

The ‘Establishment’ Strikes Back at Goldilocks anesthesia

Two years following publication of the groundbreaking textbook, Anesthesia in Cosmetic Surgery, 'the establishment' countered with Patient Safety in Plastic Surgery.

‘The establishment’ refers to the organized societies for plastic surgery and anesthesia - the American Society for Aesthetic Plastic Surgery (ASAPS), the American Society for Plastic Surgery (ASPS), and the American Society of Anesthesiologists (ASA).

Patient Safety in Plastic Surgery was recently reviewed in April 2010 Anesthesia & Analgesia. Edited by a plastic surgeon and an anesthesiologist, the book compiles 582 pages without a single reference to any of the numerous, earlier brain monitored propofol ketamine (PK) or Goldilocks anesthesia publications.

Particularly disappointing was the chapter ‘Managing Postoperative Nausea and Vomiting (PONV).’ Neither chapter author in Patient Safety in Plastic Surgery has previously published their PONV work in the prestigious New England Journal of Medicine (NEJM).

While citing Christian Apfel’s landmark PONV risk NEJM paper in the Patient Safety in Plastic Surgery PONV chapter, the authors managed to successfully avoid Apfel’s recommendations for solving the problem:

i.e. don’t give emetogenic anesthetics (stinky gases or iv narcotics) and do give PK for the optimal PONV outcomes, citing

Friedberg BL: Propofol-ketamine technique, dissociative anesthesia for office surgery: a five-year review of 1,264 cases. Aesthetic Plastic Surgery 23:70-74, 1999.

In the current edition of anesthesiology’s number one textbook, Miller’s Anesthesia, Apfel also asserts if emetogenic agents are used that the use of anti-emetics is of limited utility.

The Patient Safety in Plastic Surgery PONV chapter authors assert the "overall rate of PONV to be at 20-30%," successfully ignoring the above mentioned 1999 paper with lowest published PONV rate in the anesthesia literature at 0.6% in a high PONV risk patient group without the use of anti-emetics.

Not surprisingly, the chapter authors’ conclusion states: "PONV is a major problem for patients undergoing plastic surgery."

Can there be any doubt about the political strategy that motivated the writing of this chapter? How do intellectually honest authors ignore a decade of Goldilocks anesthesia having solved the PONV problem?

The answer may also be painfully honest.

The PONV information contained in Patient Safety in Plastic Surgery is a 'regurgitation' of the standard university teaching that ignores the accomplishments of the real world anesthesiologists and plastic surgeons that have followed the previously published Goldilocks anesthesia paradigm and solved the PONV problem without the need for anti-emetics.

There is also a complete absence of any reference to brain monitoring in Patient Safety in Plastic Surgery. Brain monitoring is a critical component of Goldilocks anesthesia.

Brain monitoring creates a numerically reproducible basis upon which PK anesthesia can deliver a 0.6% PONV rate while essentially eliminating postoperative pain requiring narcotic therapy.

Brain monitoring also eliminates the nefarious anesthesia practice of routinely over medicating patients for fear of under medicating them.

Perhaps the authors felt that further study of brain monitors was needed. However, more than 3,000 scientific papers have already been published validating the use of brain monitors to provide information not obtainable from vital signs and body weight indices of anesthetic response.

If PONV issue weren’t bad enough, the authors manage to write Patient Safety in Plastic Surgery while ignoring recent general anesthesia related deaths like that of Donde West and Stephanie Kuleba and simultaneously also ignoring the stellar safety record of Goldilocks anesthesia; i.e. no deaths, pulmonary emboli, hospital admissions for PONV or pain management, or airway disasters like aspiration and wrong site intubation.

The chapter about pulmonary embolism prevention also ignores the 2004 advice of a major medical liability carrier; namely

            “The use of general anesthesia for long plastic procedures is a subject of current debate. While some authors laud its advantages, others caution that the immobility associated with general anesthesia is a significant risk factor for thromboembolism. Newer techniques for intravenous sedation that include the use of propofol drips, often in combination with other drugs, have made it possible to perform lengthy or extensive surgeries without general anesthesia and without the loss of the patient’s airway protective reflexes.11”

Reference 11 is also the same 1999 paper Apfel references in Miller’s Anesthesia – Friedberg’s 1999 PK paper.

The editors of Patient Safety in Plastic Surgery did not appear interested in providing a dispassionate, objective assessment of patient safety in plastic surgery. Instead, the interest is clearly is providing the anesthesia and plastic surgery establishments a ‘book level’ rebuttal to the cutting edge safety of Goldilocks anesthesia presented in Anesthesia in Cosmetic Surgery.

Let the unsuspecting reader of Patient Safety in Plastic Surgery be advised.