Anesthesia & Analgesia

Date Published: 
November 2005

Ron Miller, M.D.
Editor Anesthesia & Analgesia
November 6, 2005
Model for elimination of acute postoperative pain emerged in 1993

In 1997, White cited the original propofol ketamine (PK) monitored anesthesia care (MAC) paper (1) in his textbook on ambulatory anesthesia (2). He was subsequently chided (3) for failing to mention the PK MAC technique in his 1998 review article on monitored anesthesia care (4). Although the current November 2005 supplement (5) was conceptualized in 2003, many peer reviewed publications about PK MAC have appeared prior to 2003 (6-13). One cannot dispute the conclusion of Monische, et al. (14) when they could not find any conclusive evidence for preemptive analgesia. They were not able not consider the context of the dissociative technique because there are no Level 1 studies documenting it's efficacy. For 13 years, I have not only administered PK MAC to over 3,000 patients but also personally recovered them. I am in the unique position of not only providing the first person testimonial to this fact but also published the account of 2,680 of these patients (15). Of the 2,680 patients published, only 13 experienced PONV. All 13 stated a preference for the PK MAC over their previous emetogenic anesthetic.

The key to avoiding postoperative pain is not causing intraoperative pain. The brain cannot respond to afferent signals it does not receive. Given 2-3 minutes ahead of local analgesia, a 50 mg dissociative dose of ketamine provides a 10-20 minute Pg 2 'mid-brain spinal' during which no noxious afferent stimuli reach the brain (6). No 'wind-up' is possible during the period of the introduction of local analgesia. Patients emerge from non-opioid, preemptive analgesia PK MAC quickly (11). They are either Aldrete 9 or 10, depending on whether or not their eyes are spontaneously open. Most patients have no postoperative pain or PONV. The few complaints of pain are treated successfully, in this context with 1,000 mg po acetominophen.

The key to making ketamine predictable is 'hypnosis first, then dissociation,' originally published by a plastic surgeon in 1981(16-18). The use of ketamine does not invalidate the use of BIS to titrate propofol between 60-80 (7). Incrementally titrating propofol to BIS <75 will reproducibly prevent all of the negative effects known about ketamine in other contexts (15). Yours for better ( & reproducible) outcomes,

Barry L. Friedberg, MD
Cosmetic Surgery Anesthesia
3535 E. Coast Hwy., PMB 103
Corona del Mar, CA 92625
Tel. 949-233-8845
FAX 949-760-9444
email drfriedberg@drfriedberg.com
web www.drfriedberg.com


1. White PF: Ambulatory Anesthesia & Surgery Philadelphia,
Pennsylvania, WB Saunders. 1997, Ch 1; p 11.

2. Friedberg BL: Propofol-ketamine technique. Aesth Plast Surg 17:297, 1993.

3. Friedberg BL: Dissociative monitored anesthesia care not cited.
Anesth Analg 86:1336, 1998.

4. Sa Rego MM, Watcha MF, White PF: The changing role of
monitored anesthesia care in the ambulatory setting. Anesth Analg 85:1020,1997.

5. Rowlingson JC, White PF, Viscusi ER, Rathmell, et al., Grass,
JA, Gadsden J, et al. Emerging techniques for management of acute
postoperative pain. Anesth Analg 101:S1, 2005.

6. Friedberg BL: Propofol-ketamine technique, dissociative
anesthesia for office surgery: a five year review of 1,264 cases.
Aesth Plast Surg 23:70, 1999.

7. Friedberg BL: The effect of a dissociative dose of ketamine on
the bispectral (BIS) index during propofol hypnosis. J Clin Anes 11:4, 1999.

8. Friedberg BL, Sigl JC: Bispectral (BIS) index monitoring
decreases propofol usage in propofol-ketamine office based
anesthesia. Anesth Analg 88:S54, 1999.

9. Friedberg BL: Facial laser resurfacing with propofol-ketamine
technique: room air, spontaneous ventilation (RASV) anesthesia.
Dermatol Surg 25:569, 1999.

10. Friedberg BL: Another perspective on PONV. Anesth Analg
89:1589, 1999.

11. Friedberg BL: Nonopioid analgesia improves outcomes. Anesthesiol 93:582, 2000.

12. Friedberg BL, Sigl JC: Clonidine premedication decreases
propofol consumption during bispectral (BIS) index monitored
propofol-ketamine technique for office based surgery. Dermatol
Surg 26:848, 2000.

13.Friedberg BL: Counterpoint: postoperative nausea and
vomiting. Aesth Surg J 20:490, 2000.

14. Moinche S, Kehlet H, Berg J: A qualitative and quantitative
systemic review of preemptive analgesia for postoperative pain
relief. Anesthesiol 96:725, 2002.

15. Friedberg BL: Propofol ketamine anesthesia for cosmetic
surgery in the office suite chapter in Osborne I, ed. Anesthesia
for Outside the Operating Room. Internat Anesthesiol Clin
Lippincott, Williams, & Wilkins. Baltimore, MD 41(2):39, 2003.

16. Vinnik CA: An intravenous dissociation technique for
outpatient plastic surgery: tranquility in the office facility.
Plast Reconstr Surg 67:799, 1981.

17. Friedberg BL: Hypnotic doses of propofol block ketamine
induced hallucinations. Plast Reconstr Surg 91:196, 1993.
18. Friedberg BL: Hypnosis first, then dissociation. Anesth Analg
96:911, 2003.

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