thoughts for the new year

It's obvious to all, if one wants to keep one's horses, close the barn door before they depart, not afterwards. It should be equally obvious for the issue of control of postoperative pain. Far better to prevent it from occurring than to treat it after it happens.

Why should anyone care about the 50 mg ketamine I received for my THR in addition to my SAB with BIS monitored IV propofol sedation?

Every anesthesiologist with whom I shared my story asked the same question of me: 

     What could the ketamine possibly add to that anesthetic?

I purposely went to a Southern California hospital (St. John's in Santa Monica) to have an internationally reknowned surgeon perform my surgery to be confident there was a large volume of previous THRs (5,000) with which to compare my care.

As many of you already know, for the past 17 years (& 5,000 patients), I have been giving 50 mg ketamine 3 minutes PRIOR to the stimulation of the injection of local anesthetic to the surgical field for elective cosmetic surgery AND reporting minimal postop pain with unprecedented PONV rates (0.6%) WITHOUT anti-emetics in high risk patient population (i.e. non-smoking females with high incidences of previous PONV +/or motion sickness having emetogenic cosmetic surgery - 4 out of 4 Apfel risk factors).

Understandably, many of you may have been skeptical that cosmetic surgery might have little relevance to the 'real' surgical cases most of you do involving substantial postoperative pain. Sometimes I've wondered that myself. After all, cosmetic surgey 'only' involves moving skin and fat.

When I was 'looking down the barrel' of facing my unavoidable need for a THR, I was given the opportunity to validate if it was indeed 'nifty to give fifty' for 'real' surgery.

I doubt many of you reading this blog would care to dispute that 'whacking off' a femoral head and reaming out the acetabulum doesn't constitute a significant surgical stimulus with a fair bit of postoperative pain.

Add to the surgery itself the fact that I am by 'religion' a 'devout coward' which is partly why I became an anesthesiologist. I truly do not like pain and would much prefer to not have pain than to endure it and 'tough it out.' In short, not the best surgical candidate, a genuine 'wus.'

So anxious about my surgery was I that I wrote a 3 page letter to the anesthesia service detailing my concerns about my care. I spoke to the person who assigned the cases to be sure to get a younger doc who routinely monitored propofol with a BIS.

When I met my anesthesiologist on the morning of surgery, May 6, 2008, I was able to convince him to run my propofol between 60-75 and give my 50 mg ketamine 3 minutes before my incision.

My surgeon, John Moreland, typically performs 5 THRs every Tuesday & Thurday. That 50 mg ketamine 3 minutes PRIOR to stimulation was the only difference between my anesthetic experience and the thousands of THRs before mine. The floor nurses were 'blinded' to my little experiment.

After my 2 mg midazolam premedication wore off in PACU, I was transferred to the floor. I spent another 48 hours on the floor before being discharged home.

During my stay, I required nothing for pain. Subsequently, I required nothing for PONV secondary to the opioids that are frequently used for postoperartive pain management.

Some may be willing to attribute the pain free postop course to the preop & postop local anesthetic wound infiltration and the 100 ug Duramorph in the SAB, but the floor nurses told me they still had to medicate the THRs for pain.

The most interesting aspect of my stay was the spontaneous and unrehearsed comment from each and every floor nurse that came to check on me:

"Dr. Friedberg, are you sure you had your surgery? We've NEVER seen a THR look like you. You don't LOOK like you've had surgery."

My response, in explanation, was, because of the pre-stimulation ketamine, no one 'hurt' me on the OR table.

Sure enough, I actually had more discomfort on week #2 than my first postoperative week as my brain 'caught up' to what had happened to my body.'

Yes, I understand my experience was an 'N' of one and was not 'statisitically significant.' BFD.

Personally, I did not suffer having my THR &...

professionally, my experience validated my clinical experience of 17 years and 5,000 patients!

What is your 'take home' message?'

If you never try saturating ALL of the NMDA receptors PRIOR to stimulation, you are still closing the 'barn doors' after 'the horses' have left.

It IS nifty to give fifty!

Ask yourself, is the brain weight of a 250 pound adult male 2.5X that of a 100 pound adult female? The number of NMDA receptors does not substantially vary with body weight in adults.

As long as BIS is below 75 (which for any general anesthetic it most assueredly is), you have nothing to lose and everything to gain for postoperative management.

Bonus - if you can convince the surgeon to inject some lidocaine before the incision & drop some bupivicaine in the incision prior to closing - all the better for the patient.

For all who note it, a good and sweet new year. For the rest, good tidings as well.

Barry