On March 26, 1992, Dr. Friedberg administered the first propofol ketamine monitored anesthesia care (PK MAC) at the 1441 Avocado medical building in Newport Beach, CA.
Friedberg's primacy for PK MAC hinges on the fact that only in the plastic surgery literature was the secret to administering ketamine without hallucinations. Anesthesiologists, in general, were unaware of this 1981 publication demonstrating that hypnotic doses of diazepam blocked ketamine associated hallucinations. By substituting propofol for diazepam, Friedberg created a new paradigm for patient care that essentially eliminated PONV while providing reproducible pre-emptive analgesia mitigating postoperative pain!
Others like Guit, et al. previously published the mixture of propofol & ketamine for TIVA. TIVA implies that the surgeon's local anesthesia is superfluous for the success of the technique. PK MAC does not mix the two agents. Propofol was titrated to a loss of lid reflex (LLR) and a loss of verbal response (LVR) prior to the administration of a 50 mg dissociative dose of ketamine. In contradistinction, MAC requires adequate local anesthesia for the success of the technique.
Not until December 26, 1997 was routine bispectral index (BIS) monitoring added to the technique, transforming it into the minimally invasive anesthesia (MIA)®.
MIATM occurs following an incremental propofol induction to BIS <75 prior to the administration of the 50 mg dissociative dose of ketamine and the maintenance of the level of hypnosis to BIS 60-75.
In the 15 years following the first PK MAC experience, Friedberg has published 30 letters to the editor, 14 articles and 6 book chapters, 3 in his own Cambridge University Press landmark textbook, Anesthesia in Cosmetic Surgery. His original 1993 paper has been cited in the current edition of the prestigious Miller's Anesthesia and Barasch's Clinical Anesthesia.