Published Articles

To the editor: With reference to the editorial by Pandit and Cook (1), whilst being the occasional source of PTSD, anaesthesia awareness is not lethal. However, anaesthesia over medication, the natural consequence of failing to monitor depth of anaesthesia, is lethal; specifically to the tune of nearly one American patient every day!(2)

By trending real time, frontalis muscle electromyogram (EMG) as a secondary trace, one can create a relevant device. (3) Responding to spikes in EMG activity as if they were heart rate (HR) or blood pressure (BP) changes is key to making BIS a clinically useful tool. Titrating propofol with BIS without instantaneous EMG is akin to driving one's car with only the rear view mirror.

Universal BIS/EMG monitoring could reduce anaesthesia drug usage by 30% (4) - a dramatic financial insult to anesthesia drug makers who, in turn, provide millions of various forms of support dollars to organized anesthesia. BIS monitoring is cost effective and remains the best available technology to deal with the twin problems of over- and under- anaesthesia medication. (5)

Disclaimer: Neither I, nor my non-profit Goldilocks Anesthesia Foundation, receive financial support from brain monitor or drug makers.

Refs.

1. Pandit JJ, Cook TM:National Institute for Clinical Excellence guidance on measuring depth of anaesthesia: limitations of EEG-based technology Br J Anaesth 2013:110:325-328.

2. Li G, et al: Epidemiology of Anesthesia-related Mortality in the United States, 1999-2005. Anesthesiol 2009;110:759.

3. Mathews DM, Clark L, Johansen J, et al. Increases in Electroencephalogram and Electromyogram Variability Are Associated with Increased Incidence of Intraoperative Somatic Response. Anes Analg 2012;114:759-770.

4. Friedberg BL, Sigl JC: Clonidine premedication decreases propofol consumption during bispectral (BIS) index monitored propofol-ketamine technique for office based surgery. Dermatol Surg 2000;26:848-852.

5. Klopman MA, Sebel PS: Cost-effectiveness of bispectral index monitoring. Curr Op Anesthesiol 2011;24:177

Conflict of Interest: None declared

A scholarly review of 80 randomized clinical trials looked for evidence of preemptive analgesia before incision was performed under general anesthesia.

Editorials: Prolonged use of opioids after surgery
BMJ 2014;348:1280

Re: Prolonged use of opioids after surgery

Over the past 16 years using the numerically reproducible paradigm of BIS/EMG monitored propofol ketamine (aka Goldilocks) anesthesia, NONE of >4,000 patients having a wide variety of painful, elective cosmetic surgeries required acute postoperative opioid therapy! (1)

With all respect to my learned colleagues, it is patently clear that postoperative pain is simply a function of intra-operative pain.

Side effect free intra-operative pain has been eliminated by using 'hypnosis first, then dissociation, followed by injection or incision' (2) for any surgery that breaches the skin barrier to the outside world of danger.

Injection of local analgesia after general anesthesia has been shown to not be of preemptive value. (3)

Preemptive analgesia CAN readily be obtained with 50 mg ketamine (independent of adult body weight) 3 minutes pre-stimulation. Fifty milligrams of ketamine reliably saturates 98-99% of NMDA receptors in adults. (4)

I challenge my colleagues across the pond to just give this simple paradigm a test. The difference in outcomes is dramatically obvious.

Refs.

1. Friedberg BL: Cosmetic surgery: Postoperative pain and PONV – dissociative anesthesia reconsidered. Plast Reconstr Surg 2010;125:184e-185e.

2. Friedberg BL: Hypnotic doses of propofol block ketamine induced hallucinations. Plast Reconstr Surg 1993;91:196.

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

4. Friedberg BL: Propofol-ketamine technique, dissociative anesthesia for office surgery: a five-year review of 1,264 cases. Aesth Plast Surg 1999;23:70-74.

Propofol-ketamine anesthesia is a room air, spontaneous ventilation (RASV), dissociative intravenous (IV) sedation technique reported to have a near-zero postoperative nausea and vomiting (PONV) rate. Clonidine premedication has been reported to control blood pressure intra- and postoperatively, as well as to reduce the requirements for hypnotic agents. The Bispectral Index® (BIS®) monitor is a reproducible, objective, observer independence, quantitative measurement of the hypnotic state.

Patients feel no pain, yet they respond to the surgeon's commands. And After that, they don't remember a thing. Welcome to the world of conscious sedation. Here are 10 pearls to fine-tune your regimen.

There are no emergency facelifts in my practice. Ironically, the office based anesthesiologist, while dealing with a truly elective patient population, is actually held to a higher standard of care than his institutional based counterpart.

Propofol-ketamine technique is a room air, spontaneous ventilation (RASV), intravenous dissociative anesthetic technique which simulates the operating conditions of general anesthesia without the increased equipment requirements or costs. A total of 2059 procedures were performed on 1264 patients by 38 different surgeons. There were no hospital admissions for postoperative nausea and vomiting (PONV) or uncontrolled pain. All patients were pleased with their anesthetic and no hallucinations were reported. Cost:benefit analysis is presented as well as discussion of dissociative anesthesia being exempt from current California law (AB595).