Anesthesiology

Michael Todd, M.D.
Editor in Chief
Anesthesiology

To the Editor,

Droperidol v NOPA

Now that TJ Gan, et. al. (1), B Ben-David, et. Al. (2), P Bailey, et. Al. (3) have screamed 'bloody murder' about the FDA 'black box' warning on droperidol, it might be a good time to reconsider the algorithm that, I believe, is responsible for the overwhelming majority of postoperative nausea and vomiting (PONV). Despite the impressive list of causes of PONV, the entire list is worth about 0.1% of the problem compared to the '800 pound gorilla in the living room;' namely, the routine use of emetogenic agents like opioids and inhalational vapors.

As a freshly minted graduate of Stanford in '77, I believed the best anesthetic was some regional (i.e. spinal, epidural, axillary or Bier block) with IV sedation. 1977 was before pulse oximetry or propofol. Seeing my patients postoperatively and comparing the way the general anesthesia (GA) patients looked with the regionals with sedation, the regional patients looked a whole lot less 'wrung out' for want of a better term. Not much has changed my mind since.

I have finished logging my cases for ten years worth of propofol ketamine (PK), room air, spontaneous ventilation (RASV), non-opioid, preemptive analgesia (NOPA), a dissociative MAC. PK proposes we anesthesiologists remove ourselves from the 'analgesia' business and provide a dissociative window of opportunity for the surgeon to inject local into a motionless patient, simulating the conditions of GA with the minimal, non-emetogenic trespass of propofol sedation (4). Loss of lid relfex (LLR) & loss of verbal response (LVR) was the level of propofol (5) I used to titrate to before the BIS monitor. I now use BIS = 70-75 before giving the ketamine and most patients retain the lid reflex (6).

My outcomes: 13 PONV out of 2,680 patients (0.5%), one third of whom had had previous PONV & no antiemetic prophylaxis. As long as one remains wedded to the notion that every anesthetic must include some, judicious use of opioids, these outcomes are simply not believable. Step 'out of the box,' try PK and get the same results.

In June '97, I gave my last dose of benzodiazepine, December '97 was the last dose of opioid, and no neuromuscular (NM) blockers. I have added 50 mg rofecoxib to the premedication of 200 mcg clonidine po 30-60 minutes before surgery. Measuring the level of propofol with the BIS has transformed ketamine into a most predictable, therefore, useful agent. My caseload includes abdominoplasty, subpectoral breast augmentations, liposuction, facelifts, browlifts, rhinoplasty, blepharoplasty, otoplasty, and facial resurfacing. PK can work for the whole panoply of plastic cases, in addition to hernias, breast biopsy, simple mastectomy, gynecologic laparoscopy, and lithotripsy.

Consider PK before 'fuming' over the FDA 'black box' droperidol warning. PK also obviates the concerns about the fentanyl shortage. Despite the lack of a Level I study, PK RASV NOPA MAC is reproducible. Many in the Society for Office Based Anesthesia (SOBA, www.soba.org), the Society for Ambulatory Surgery (SAMBA, www.sambahq.org) and others around the globe have reported via e-mail that they have the same positive outcomes as I have published. The positive PK outcomes will be rewarded by patients, surgeons and nursing staff.

PK is being taught by Meyer ('Mike') Rosenthal, M.D. at Stanford as well as Ann Showan, M.D. at the University of Pennsylvania. "Gentlemen, this is no humbug." More details and cookbook are scheduled to appear in Volume I, 2003 International Anesthesiology Clinics, edited by Irene Osborn, M.D. and Volume III, 2003 International Anesthesiology Clinics, edited by Andrew Herlich, M.D.

Yours for better outcomes,

Barry L. Friedberg, M.D.