. 1
( 13)


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One major by-product of the aging baby-boom generation has been a surg-
ing interest in cosmetic surgery. Outpatient cosmetic surgery clinics have
sprouted up in droves all over the United States, and the number of cosmetic
procedures performed in 2005 increased by more than 95% from the previ-
ous year. Although procedures like facelifts and abdominoplasties are consid-
ered minimally invasive, the anesthetic protocols and regimens involved are
often overly complex and unnecessarily toxic. Major complications involv-
ing anesthesia in this (and any other) surgical milieu can range from severe
postoperative nausea and vomiting (PONV) to postoperative pain to mor-
tality. Although mortality may be rare, there have been many cases in which
perfectly healthy cosmetic surgery patients require emergency intervention
due to a severe complication involving anesthesia. In recent years, many new
anesthetic protocols have been developed to reduce the incidence of PONV
and other complications, while ensuring that effective pain management and
level of “un-awareness” during surgery are always maintained.

Barry L. Friedberg, M.D., is a volunteer assistant professor at the Keck School
of Medicine, University of Southern California. Since 1992, he has practiced
exclusively in the subspecialty of of¬ce-based anesthesia for elective cosmetic
surgery. He founded the Society for Of¬ce Anesthesiologists (SOFA) in 1996
that he merged in 1998 with the Society for Of¬ce Based Anesthesia (SOBA),
another non-pro¬t, international society dedicated to improving patient
safety through education. Dr. Friedberg is the developer of propofol ketamine
(PK) technique designed to maximize patient safety by minimizing the degree
to which patients need to be medicated to create the illusion of general
anesthesia, that is, “no hear, no feel, no recall.”
Anesthesia in Cosmetic
Assistant Professor in Clinical Anesthesia
Volunteer Faculty
Keck School of Medicine
University of Southern California
Los Angeles, CA
Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo

Cambridge University Press
The Edinburgh Building, Cambridge CB2 8RU, UK
Published in the United States of America by Cambridge University Press, New York
Information on this title: www.cambridge.org/9780521870900

© Cambridge University Press 2007

This publication is in copyright. Subject to statutory exception and to the provision of
relevant collective licensing agreements, no reproduction of any part may take place
without the written permission of Cambridge University Press.
First published in print format 2007

eBook (NetLibrary)
ISBN-13 978-0-511-28482-3
ISBN-10 0-511-28635-X eBook (NetLibrary)

ISBN-13 978-0-521-87090-0
ISBN-10 0-521-87090-9

Cambridge University Press has no responsibility for the persistence or accuracy of urls
for external or third-party internet websites referred to in this publication, and does not
guarantee that any content on such websites is, or will remain, accurate or appropriate.

Every effort has been made in preparing this book to provide accurate and up-to-date
information that is in accord with accepted standards and practice at the time of
publication. Nevertheless, the authors, editors, and publisher can make no warranties that
the information contained herein is totally free from error, not least because clinical
standards are constantly changing through research and regulation. The authors, editors,
and publisher therefore disclaim all liability for direct or consequential damages resulting
from the use of material contained in this book. Readers are strongly advised to pay careful
attention to information provided by the manufacturer of any drugs or equipment that
they plan to use.
Come mothers and fathers
Throughout the land
And don™t criticize
What you can™t understand
Your sons and your daughters
Are beyond your command
Your old road is
Rapidly agin™
Please get out of the new one
If you can™t lend your hand
For the times they are a-changin.™

“ Robert “Bob Dylan” Zimmerman
“The Times They Are A-Changin,” 1963
To my parents, my ¬rst teachers, who taught me it was acceptable to not be
like everyone else as long as I aspired to be the best I could be.

To Willy S. Dam, M.D., of Bispebjerg Hospital, Copenhagen, my ¬rst
anesthesia teacher, who encouraged me to become an anesthesiologist.

To all the patients who have suffered from previous anesthetics and who
may now be relieved of their PONV, postoperative pain, and prolonged

Foreword Page xi
Adam Frederic Dorin, M.D., M.B.A.
Acknowledgments xiii
Introduction vx
C. Philip Larson, Jr., M.D., C.M., M.A.
Preface xvii
Barry L. Friedberg, M.D.
List of Contributors xix

Propofol Ketamine with Bispectral Index (BIS) Monitoring 1
Barry L. Friedberg, M.D.

Preoperative Instructions and Intraoperative Environment 14
Barry L. Friedberg, M.D.

Level-of-Consciousness Monitoring 23
Scott D. Kelley, M.D.

The Dissociative Effect and Preemptive Analgesia 39
Barry L. Friedberg, M.D.

Special Needs of Cosmetic Dental Patients 47
James A. Snyder, D.D.S.

Propofol Ketamine in the UK, Propofol Ketamine Beyond
Cosmetic Surgery 59
Chris Pollock, M.B.

Propofol Ketamine Beyond Cosmetic Surgery: Implications for
Military Medicine and Mass-Casualty Anesthesia 68
Joel W. McMasters, M.D., M.A.J., M.C., U.S.A.

Lidocaine Use and Toxicity in Cosmetic Surgery 72
Adam Frederic Dorin, M.D., M.B.A.

x Contents

Local Anesthetic Blocks in Head and Neck Surgery 84
Joseph Niamtu III, D.M.D.

Local Anesthetics and Surgical Considerations
for Body Contouring 106
Rodger Wade Pielet, M.D.

Intravenous Anesthesia for Cosmetic Surgery 112
David Barinholtz, M.D.

Regional Anesthesia for Cosmetic Surgery 131
Holly Evans, M.D., F.R.C.P., and Susan M. Steele, M.D.

General Inhalation Anesthesia for Cosmetic Surgery 155
Meena Desai, M.D.

Preanesthetic Assessment of the Cosmetic Surgery Patient 171
Norman Levin, M.D.

Psychological Aspects of Cosmetic Surgery 182
David B. Sarwer, Ph.D., Canice E. Crerand, Ph.D., and Lauren M. Gibbons, B.A.

The Business of Of¬ce-Based Anesthesia for Cosmetic Surgery 199
Marc E. Koch, M.D., M.B.A.

The Politics of Of¬ce-Based Anesthesia 206
David Barinholtz, M.D.

Staying Out of Trouble: The Medicolegal Perspective 225
Ann Lofsky, M.D.

APPENDIX A. A Guide to Perioperative Nutrition 241
David Rahm, M.D.

APPENDIX B. Re¬‚ections on Thirty Years as an Expert Witness 248
Norig Ellison, M.D.

Index 257

Physicians, like all people, live in a world that is proscribed more by what we
do in rote fashion every day than by what we understand in any meaningful
way. Our modern lives have become so harried that most of us barely have
enough time to pause and re¬‚ect on what we have done and where we are
Dr. Barry L. Friedberg, at great personal effort and time, has put forth
this pearl of a book: ideas, methods of practice, and salient knowledge on
the cutting edge of modern medical practice as they apply to the world of
minimally invasive anesthesia for cosmetic surgery. As many of our practices
prove every day in operating rooms across the United States and beyond, the
information and anecdotes provided here apply equally well to a whole host
of different anesthetic and surgical settings.
Modern science is replete with heroic strides in improving patient care and
decreasing perioperative morbidity and mortality”and yet, today, we still do
not understand the underlying mechanisms of general anesthesia on the brain,
much less the construct of consciousness itself!
The ¬eld of anesthesiology and perioperative medicine achieved unprece-
dented gains in patient outcomes through the advent of pulse oximetry decades
ago. Since then, we have re¬ned our techniques, implemented new airway
devices, decreased postoperative nausea and vomiting, improved our times to
“street readiness,” and done a better job of managing pain. Now is the time to
move to the next level of patient care.
Dr. Friedberg, through unrelenting drive and perseverance, has brought
to light the bene¬ts of the age-old concept that “less is more.” Through the
use of minimally invasive anesthetic techniques, a resurgence in the prudent
use of ketamine via the propofol-ketamine (PK) technique, and the application
of brain wave (level-of-consciousness) monitoring, Dr. Friedberg has brought
anesthesia care to a higher plane.
When Albert Einstein died, curious scientists autopsied his brain in the
futile quest to glean some insight into one of humanity™s greatest minds. They
were desperately seeking answers to how this one man transformed Newtonian
physics into an advanced understanding of the universe itself. Today, physicists
struggle with String Theory and other abstract mathematical concepts to solve
the ultimate riddle of bridging relativity theory with quantum mechanics in
one grand unifying equation. But back in 1905, when Einstein™s ¬rst papers
were reaching the scienti¬c print, he was greeted as a heretic. At one point, a
group of one hundred of the world™s most renowned scientists signed a doc-
ument stating that Mr. Einstein was not correct in his radical departure from

xii Foreword

conventional theory. Albert Einstein is reported to have replied, in paraphrase,
“if they were so sure that they were right and I was wrong, then why does this
letter contain one hundred signatures”in that case, they should need only
one signature!”
In this same vein, there have been those detractors who espouse opposition
to some of the elegant medical practices and insights put forth by Dr. Friedberg.
To those voices, hiding in the shadow of inexperience, I say with a loud and
con¬dent voice”come join us, read on, and enjoy this journey along the road
to greater insight and knowledge. Some have suggested that Dr. Friedberg is
“rede¬ning anesthesia””and, in some contexts and practice paradigms, this
may be true. I like to think of his work, and this book, as a stepping-stone to
the next level of patient care.

Adam Frederic Dorin, M.D., M.B.A.
Medical Director
Grossmont Plaza Surgery Center
San Diego, CA

I wish to express my appreciation to the following individuals for their help
during the creation of this book.
Raymond Hasel, M.D., an early propofol ketamine adopter, for his valuable
suggestions regarding my chapters.
The librarians at Hoag Hospital Medical Library, especially Cathy Drake,
Michele Gordaon, and Barbara Garside for their generous support.
Marc Strauss, my editor and friend, who displayed extraordinary sagacity
and forebearance in making this book a reality.
Ken Karpinski, my project manager, who guided me through the production
Brian Bowles for his help with the copyediting and Constance Burt for her
assistance with the ¬nal proo¬ng and corrections to the manuscript.


Anesthesiology has undergone remarkable changes in recent years. Among
them is the development of anesthesia subspecialties and of anesthesiologists
who focus most or all of their time in one area of anesthesia practice. This
change has several advantages for patients, surgeons, and anesthesiologists.
For one, the anesthesiologist learns the needs and expectations of the surgeon,
which optimizes surgical outcome for patients. Furthermore, knowing what
to expect, the anesthesiologist is better able to adjust both the doses and
timing of drugs so that patients are adequately anesthetized for surgery but
then emerge from anesthesia in a timely and comfortable manner. Nowhere are
these issues more important than when surgery is performed in the ambulatory
or of¬ce-based setting. Expectations are that patients undergoing surgery in
these settings will go home the same day. Resources for extended care are
usually nonexistent, as they should be.
Providing anesthesia for of¬ce- or clinic-based cosmetic surgery has
emerged as one subspecialty area for anesthesiologists. For patients, conve-
nience is greatly enhanced and costs are greatly decreased in of¬ce- or clinic-
based cosmetic surgery. To provide the best anesthetic care in this specialized
setting requires certain skills that are not emphasized in most anesthesia train-
ing programs. Fortunately, we are blessed with a resource prepared by a highly
skilled and experienced anesthesiologist.
In this book, Dr. Barry L. Friedberg has assembled a compendium of his
¬fteen years of providing anesthesia care in the of¬ce setting. Where scienti¬c
documentation is available, Dr. Friedberg provides it. Where it is lacking,
he guides the reader with recommendations that represent both reasoned
judgment and innovative, effective results. He knows what works and what
doesn™t and explains his views in text and illustrations that are concise and
Any anesthesiologist contemplating providing anesthesia care for cosmetic
surgery, regardless of the surgical setting, needs to read this book. For those
providing care in the of¬ce or clinic setting, it is virtually mandatory. By
reviewing this text, anesthesiologists will avoid the pitfalls that exist in this
practice and conclude their days with grateful patients and happy surgeons.

C. Philip Larson, Jr., M.D., C.M., M.A.
Professor Emeritus
Anesthesiology & Neurosurgery, Stanford University
Professor of Clinical Anesthesiology
David Geffen School of Medicine at UCLA


The very essence of leadership is that you have a vision.
”Theodore Hesburgh

Caesar™s Gallic Wars begins with the observation that “All Gaul is divided into
three parts.” Anesthesia in Cosmetic Surgery is also divided into three parts.
Part I, Chapters 1“10, is devoted to minimally invasive anesthesia (MIA) r
for minimally invasive surgery. (The United States Patent and Trademark
Of¬ce [USPTO] granted trademark serial number 76/619,460, ¬le number
067202-0312946 to minimally invasive anesthesia [MIA] to Dr. Friedberg in
Part I advances the premise of a unitary anesthetic technique for all elective
cosmetic surgery. Part I challenges the belief that only some types of elective
cosmetic surgery are suitable for intravenous sedation. Many readers may be
similarly challenged by the description of abdominoplasty, an extraperitoneal
procedure, as a minimally invasive surgery.
Inasmuch as the MIA technique is not universally applicable for every sur-
gical personality, Part II, Chapters 11“13, is dedicated to providing a compre-
hensive view of other anesthetic techniques administered by dedicated anes-
thesia professionals. Deliberately omitted are those approaches of oral and
intravenous sedation directed by the surgeon in the absence of a dedicated
anesthesia provider.
There is much about the practice of anesthesia in cosmetic surgery that
is not speci¬cally related to anesthetic technique. Part III, Chapters 14“18,
and Appendices A and B illustrate the chasm between the medically indicated
(third-party reimbursed) anesthesia practice and that particular to anesthesia
for elective cosmetic surgery.
The reader who demands Level 1 study to accept new solutions to clinical
problems is reminded that neither aspirin nor penicillin ever had a Level 1
study to validate their ef¬cacy. Nonetheless, both are well-accepted therapeutic
agents. The ef¬cacy of the MIA technique will eventually make it a widely
accepted practice.
“Insanity” is sometimes de¬ned as performing the same act in the same way,
over and over, yet expecting a different outcome. Only by changing the “script”
can outcomes be improved. MIA for minimally invasive surgery represents
a paradigm shift or change in the “script” for the anesthetic management of
the patient intraoperative experience. MIA technique is not only differ-
ent from anesthetic techniques described in Part II but also safer. Superior
postoperative outcomes for postoperative nausea and vomiting (PONV) and
pain management with MIA technique are described in Part I.

xviii Preface

In 2007, American soldiers are dying in Afghanistan and Iraq. HIV/AIDS
is still causing deaths throughout the world. Deaths from malnutrition, star-
vation, and natural disasters still plague the third world. A nuclear disaster
from weapons of the former Soviet Union in the hands of rogue nations or
terrorists remains a threat. According to the National Highway Transportation
and Safety Administration (NHTSA), on American highways in 2004, there
were 105 daily deaths (or 38,253 for the year) from motor vehicle accidents.
Whereas death is a constant in life, the public has grown somewhat able to
accept these kinds of deaths. Death surrounding elective cosmetic surgery,
surgery without medical indication, is never an acceptable outcome for the
patient, the patient™s family, the anesthesiologist, the surgeon, or the lay public.
There is a “perfect storm” of forces that have made this book not only pos-
sible but necessary. The baby-boom or “me generation,” born 1946 to 1964,
is beginning to age. Social forces creating the “sandwich” effect of simultane-
ously caring for parents and children have created economic forces dictating
that this generation will postpone retirement. The work force is a competitive
environment with a heavy emphasis on a youthful appearance. The combina-
tion of narcissism and the need to remain competitive at work has created a
huge impetus for “boomers” to seek cosmetic relief of the aging process.
In the course of seeking cosmetic surgery, many patients receive general
anesthesia, opioid-based IV sedation, or regional anesthetics in hospital sur-
gicenter (ASC) and of¬ce-based settings (see Part II). When death occurs in
the of¬ce-based setting, the public and media ¬nd it unacceptable. “Dying to
be beautiful,” read the headlines. States like Florida, California, New York, and
others have rushed to regulate the of¬ce surgical suite because it is frequently
the site for elective cosmetic surgery.
Sadly, what remains is the absurd situation that it is acceptable to have a
death from a pulmonary embolism following an abdominoplasty in a hospital
or ASC setting but not the exact same outcome in an of¬ce-based setting.
The emerging hypocrisy is that the hospital and ASC lobbies in Florida (and
others to follow) have persuaded the legislatures to mandate reporting of all
mortalities from of¬ce-based cosmetic surgery while remaining exempt from
the same requirement. This is clearly not in the interest of public safety. All
deaths from elective cosmetic surgery should be subject to the same reporting
and scrutiny as those in the of¬ce-based setting.
The old maxim that “while the surgeon can only maim, the anesthesiologist
can kill” rings true in the effort to affect the ultimate negative anesthesia
outcome. How can tragic deaths in cosmetic surgery be avoided? Is the answer
somewhere in the future with better drugs or better monitors? It is not possible to
get the right answer by asking the wrong question. “Have we overlooked existing
drugs, techniques, and/or monitors that can provide for a safer anesthetic with
better outcomes?” is, perhaps, the more insightful question. The answer to this
question is at the heart of the MIA technique.

Barry L. Friedberg, M.D.
Corona del Mar
List of Contributors

David Barinholtz, M.D. Marc E. Koch, M.D., M.B.A.
President and CEO Founder and CEO
Mobile Anesthesiologists, LLC Somnia Anesthesia Services, Inc.
Chicago, IL New Rochelle, NY

Meena Desai, M.D. C. Philip Larson, Jr., M.D., C.M., M.A.
Managing Partner Professor Emeritus
Nova Anesthesia Professsionals Anesthesiology & Neurosurgery
Villanova, PA Stanford University
Palo Alto, CA
Adam Frederic Dorin, M.D., M.B.A.
Professor of Clinical Anesthesiology
Medical Director
David Geffen School of Medicine at UCLA
Grossmont Plaza Surgery Center
Los Angeles, CA
San Diego, CA
Norman Levin, M.D.
Norig Ellison, M.D.
Chief, Department of Anesthesiology
Professor of Anesthesia
Century City Hospital
University of Pennsylvania
Los Angeles, CA
Philadelphia, PA
Ann Lofsky, M.D.
Holly Evans, M.D., F.R.C.P.
Staff Anesthesiologist
Associate Professor
Saint John™s Hospital
Department of Anesthesiology
Santa Monica, CA
Division of Ambulatory Anesthesiology
Anesthesia Consultant and Governor Emeritus
Duke University Medical Center
The Doctors™ Company
Durham, NC
Napa, CA
Barry L. Friedberg, M.D.
Joel McMasters, M.D., M.A.J., M.C., U.S.A.
Assistant Professor in Clinical Anesthesia
Assistant Chief of Anesthesia
Volunteer Faculty
Director of Total Intravenous Anesthesia
Keck School of Medicine
Brooke Army Medical Center
University of Southern California
San Antonio, TX
Los Angeles, CA
Joseph Niamtu III, D.M.D.
Scott D. Kelley, M.D.
Private Practice
Medical Director
Cosmetic Facial Surgery
Aspect Medical Systems, Inc.
Richmond, VA
Norwood, MA

xx List of Contributors

Rodger Wade Pielet, M.D. David B. Sarwer, Ph.D.
Clinical Associate Departments of Psychiatry and Surgery
Department of Surgery The Edwin and Fannie Gray Hall Center for
University of Chicago Human Appearance and the Weight
Chicago, IL and Eating Disorders Program
University of Pennsylvania School of Medicine
Chris Pollock, M.B.
Philadelphia, PA
Consultant in Pain Management and
Anaesthesia James A. Snyder, D.D.S.
Hull and East Yorkshire Hospital Trust Founder and CEO
Hull, England Center for Dental Anesthesiology
Alexandria, VA
David Rahm, M.D.
President and CEO Susan M. Steele, M.D.
Vitamedica Professor
Manhattan Beach, CA Department of Anesthesiology
Division of Ambulatory Anesthesiology
Duke University Medical Center
Durham, NC

1 Propofol Ketamine with Bispectral
Index (BIS) Monitoring
Barry L. Friedberg, M.D.

Postoperative Nausea and Vomiting (PONV)
How are PONV, preemptive analgesia, and postoperative pain
management related?
Beware Laryngospasm
Why Ketamine?
Making ketamine predictable
Fluid management
Major confounding principle
BIS as ¬anchetto
Postoperative pain management

mastectomy. One may consider risk-bene¬t ratios of dif-
fering anesthetic regimens in medically indicated surgery.
Anesthesiologists are trained to administer anesthesia for However, surgery without medical indication should not
surgery. Elective cosmetic surgery is commonly performed accept any avoidable risk. Halogenated inhalation anes-
in an of¬ce-based facility with patients discharged to thetics are triggering agents for malignant hyperthermia
(MH),2 carry an increased risk of deep venous thrombo-
home. However, elective cosmetic surgery differs from
sis with potential pulmonary embolism,3 and are eme-
elective or emergency surgery in many substantial aspects
togenic.4 If the patient is interested and the surgeon is
(see Tables 1-1 and 1-2).
“Cosmetic surgery is almost always elective, and patients willing, all cosmetic procedures can be performed under
are almost always in good health. The patient, however, local only anesthesia. Therefore, any additional anesthetic
is willing to risk this good health (at least to a limited agents should be subject to the highest justi¬cation.
extent) in order to experience improvements in physical Most patients desire some alteration of their level of con-
appearance, and perhaps more importantly, self-esteem, sciousness from fully awake through completely asleep.
body image, and quality of life.”1 Given that all known risks should be avoided, when
There is no medical indication for elective cos- possible, then which agents are best suited to the task,
metic procedures, excluding breast reconstruction post- what monitors should be employed, and to what level

2 Barry L. Friedberg

Table 1-1. Elective cosmetic procedures Table 1-2. Cosmetic procedures by type from PK
MAC/MIA„ technique case log March 26,
1992 “ March 26, 2002 12
Commonly performed cosmetic surgical procedures.
All procedures have successfully been anesthetized
with PK MAC/MIA„ technique in the of¬ce-based N %
Liposuction 663 (25)
1. Rhinoplasty (closed or open) Breast augmentation 489 (18)
2. Liposuction or suction assisted lipoplasty (SAL) Facial resurfacing mechanical 389 (14)
3. Blepharoplasty (open, transconjuctival, or abrasion, chemical peel, or
endoscopic) laser resurfacing
4. Rhytidectomy (open or endoscopic) Rhytidectomy 305 (11)
5. Breast augmentation, subglandular, subpectoral Blepharoplasty 198 (7)
(via areaolar, inframammary, transaxilllary, or Rhinoplasty 81 (3)
transumbilical approach) Fat transfer 57 (2)
6. Hair transplantation with or without scalp Abdominoplasty 54 (2)
reduction Composite or misc. procedures 447 (18)
7. Facial resurfacing (laser, chemical peel, or Total 2,683 (100)
mechanical dermabrasion)
8. Brow lift (coronoplasty or endoscopic)
9. Abdominoplasty (classical or simple skin)
10. Otoplasty
“We hold the basic premise that the less the involvement
11. Genioplasty (mandibular advancement or
of the patient™s critical organs and systems (i.e., the lower
12. Facial implants (malar and mandibular with the concentration of the agent, or the less ˜deep™ the anes-
silicone or autologous fat) thesia), the less will be the damage to the patient, whether
13. Lip enlargement (autologous fat transfer,
this be temporary or permanent.”6
radiated cadaver material [Alloderm ],
“For the anesthetic itself, overall experiences indicate
Gortex extrusions, Restylane, Juvaderm,
etc.) that the least amount of anesthetic that can be used is the
14. Platsyma band plication
best dose. Local and monitored anesthesia care (MAC) is
15. Composite procedures; i.e., (a) endoscopic brow
preferable to regional. Regional techniques are preferable
lift and endoscopic rhytidectomy, with open
to general anesthesia.”7
platysma band plication, (b) blepharoplasty,
rhinoplasty, and rhytidectomy, or (c) breast
augmentation with abdominoplasty

Table 1-3. Minimally invasive surgeries
appropriate for BIS-monitored PK MAC, the
MIA„ technique
of anesthesia should be administered (i.e., minimal seda-
tion [“anxiolyis”], moderate [“conscious”] sedation, deep 1. All cosmetic procedures (see Table 1-1)
sedation, or general anesthesia [GA])? (See Appendix 1-1, 2. Gyn: laparoscopy (tubal ligation, fulgeration
De¬ning Anesthesia Levels). If better outcomes are the
3. Ortho: arthoscopy
goal, doesn™t minimally invasive anesthesia for minimally
4. Urology: lithotripsy
invasive surgery make sense?5 (See Table 1-3.) 5. Gen. surg.: herniorraphy & breast cancer
6. Neuro: microdiscectomy, microlaminectomy,
carpal tunnel release
WHY IS MINIMALLY INVASIVE 7. sedation for morbidly obese
8. peripheral injuries in U.S. Army ¬eld hospitals in
Iraq, Afghanistan
“Less is more” is a Mies Vanderohe principle applied to
Cases being performed with PKRa TIVA
the Bauhaus school of minimalist architecture. “Doing
1. U.S. Army neurosurgery in Iraq.
more with less” is a Buckminster Fuller concept of housing a Propofol-Ketamine-Remifentanil

applied to his geodesic domes.
Propofol Ketamine with Bispectral Index (BIS) Monitoring 3

“When possible, procedures longer than three or four
Table 1-4. BIS levels and levels of
hours should be performed with local anesthesia and intra-
venous sedation because general anesthesia is associated
with deep venous thrombosis at much higher rates under BIS Sedation/Anesthesia Level
98“100 Awake
prolonged operative conditions.”3
78“85 Minimal Sedation (“Anxiolysis”)
“Newer techniques for intravenous sedation that Moderate (“Conscious”) Sedationa
include the use of propofol, often in combination Deep Sedationb
with other drugs, have made it possible to perform General Anesthesiac
+ systemic
lengthy or extensive procedures without general anesthe-
sia and without the loss of the patient™s airway protective
<45, >1 hr.
a With moderate sedation, passive maneuvers like extension
“When you can measure what you are speaking about,
and rotation of the head or shoulder pillow may be all that
and express it in numbers, you know something about it;
are necessary to maintain the airway.
but when you cannot measure it, when you cannot express b With deep sedation, active maneuvers, like nasal airway or
it in numbers, your knowledge is of a meager and unsat- LMA, may be required to maintain airway patency.
c See Appendix 1-1.
isfactory kind; it may be the beginning of knowledge, but
you have scarcely, in your thoughts, advanced to the stage
of science.” (William Thompson, knighted Lord Kelvin. increased C-reactive protein levels with BIS <45 for more
than 50% of the cases.14
Popular lectures and addresses [1891“1894])
The bispectral index (BIS) monitor facilitates a numer- The BIS monitor does not replace traditional vital-sign
ical expression of the hypnotic component (anesthesia = monitoring, that is, EKG, NIABP, SpO2 , (or EtCO2 when
hypnosis + analgesia) of the anesthetic state and may per- indicated). When measured, the EtCO2 typically runs
mit a reasonable inference about the analgesic state. Heart between 38“42 with the MIA„ technique. The EtCO2
rate, blood pressure, and other clinical signs are noto- offers the display of the waveform of the patient™s res-
riously unreliable indicators of anesthetic depth.10 BIS piration. Many experienced anesthesiologists are capable
provides new information about patients that is simply of assessing adequate respiratory movement without this
unavailable from any other vital or clinical sign.11 BIS, as information. Over 3,000 PK MAC cases have been safely
an index, has no units. The scale is 0“100, with 100 repre- anesthetized without EtCO2 monitoring.
senting awake and zero representing isoelectric (or zero) Titrating anesthesia with BIS trend is limited by the
brain activity. Hypnosis compatible with general anesthe- fact that the processing required for the BIS algorithm is
sia (GA) occurs between BIS 45“60. BIS 45“60 with sys- delayed 15“30 seconds behind real time. This delay has
temic analgesia de¬nes general anesthesia. BIS 60“75 with given rise to the legitimate criticism that BIS does not
adequate local analgesia is a major part of the MIA„ tech- predict patient movement. BIS, a measure of the hypnotic
nique. Patients who received MIA neither hear, nor feel, state, was not designed to predict patient movement (see
nor remember their surgical experience.12 Chapter 3).
Monk et al. published an associated 20% increase in the EMG is the instantaneous display of the frontalis muscle
one-year mortality risk associated with every hour of BIS activity if the XP software version of the BIS A2000, or later,
<45.13 Therefore, BIS <45 for cumulative periods greater is used. Inadequate analgesia leading to patient movement
than one hour must be considered as overmedicating. is predictable if the EMG is selected from the advanced
The routine practice of overmedicating for fear of under- screen menu to trend as a secondary trace. A spike in
medicating is no longer a desirable or acceptable practice (see EMG (when BIS is 60“75, in spontaneously breathing
Table 1-4). patients) nearly always predicts inadequate analgesia, pre-
Monk et al. postulated that the increase in one-year ceding patient movement (see Fig. 1-1). The anesthesiol-
anesthetic mortality might be related to an in¬‚ammatory ogist should utilize the 15“30 second delay in the change
response from excessively deep anesthesia.13 A more recent of the BIS value to simultaneously bolus propofol while
prospective, randomized controlled study demonstrated encouraging the surgeon to supplement the local analgesia.
4 Barry L. Friedberg

Figure 1-1. Incremental propofol induction began 08:45. Ketamine 50 mg IV administered 08:47, BIS = 63. In this particular case, BIS
increases post-ketamine dose. However, the increase does not defeat the ability to titrate propofol to BIS 60“75!

Postoperative Nausea and Vomiting (PONV) Apfel™s recent NEJM article identi¬es the highest PONV
risk group of patients as nonsmoking females, with a his-
Macario et al. conducted a statistically validated survey of
tory of previous PONV and/or motion sickness, having
a panel of expert anesthesiologists on what postoperative
emetogenic (i.e., elective cosmetic) surgery of two or more
anesthetic outcome they believed patients most wanted
hours.4 Apfel™s criterion of high risk applies exceptionally
to avoid.15 The anesthesiologists concluded that pain was
well to Friedberg™s previously referenced series of 2,683
the number one anesthesia outcome patients most desired
to avoid. A follow-up, similarly statistically validated sur-
Elective cosmetic surgery anesthesia for the “rich and
vey of patients™ anesthesia outcomes they most desired to
avoid was emesis!16 Clearly, a disconnect exists between famous” of Beverly Hills and Newport Beach is the highest
risk PONV population! This conclusion re¬‚ects the south-
what anesthesiologists believe about their patients and
ern California geographic bias of the author. There are
what the patients actually want most to avoid. A potential
many other such communities worldwide.
explanation could be that patients who consent for elec-
The MIA„ technique is not perfect but contextually
tive surgery expect to have some postoperative discom-
nonemetogenic. Without any antiemetic prophylaxis, this
fort but do not want their pain to be compounded by
highest risk group of patients experienced a total of thir-
teen PONV events for an unprecedented 0.5% PONV
rate!12 A 50 mg dissociative dose of ketamine at BIS <75
How are PONV, preemptive analgesia, and
propofol levels eliminates the noxious input of the injec-
postoperative pain management related?
tion of local analgesia while avoiding emetogenic agents
There is a consensus among PONV authorities like Apfel,
like the halogenated inhalational vapors and intravenous
Chung, Gan, Scuderi, and White, that both inhalational
anesthetics and opioids are emetogenic agents. “In the con-
Lidocaine provides intraoperative analgesia with
text of [emetogenic] anesthesia, postoperative pain man-
agement and opioid related PONV remain problems.”17 bupivicaine providing postoperative analgesia. In this con-
text, it has been extremely rare for patients to require (eme-
In the context of emetogenic anesthesia, experts advise
“multimodal” prophylaxis in the highest risk group.18 togenic) opioid relief of their postoperative discomfort.
Propofol Ketamine with Bispectral Index (BIS) Monitoring 5

Elimination of all emetogenic triggers de¬nes nonopioid, operating room nursing staff. This disturbing scenario is
preemptive analgesia (NOPA). NOPA is the hallmark of best minimized by promptly giving IV lidocaine when the
the MIA„ technique. In Friedberg™s ¬fteen-year experi- patient coughs or sneezes.
ence, no patients have been admitted to the hospital fol-
lowing PK MAC/MIA„ technique for either PONV or
unmanageable pain.
Beware Laryngospasm
Something old (ketamine), something new (BIS-moni-
No technique is perfect. Classical laryngospasm can
tored propofol hypnosis), something borrowed (diazepam
be diagnosed by the characteristic “crowing” sound
ketamine technique19 ), no one blue (SpO2 >90% on room
generated by a small gap in the vocal cords owing to
their incomplete closure. With ketamine-associated laryn-
gospasm, the vocal cords most commonly close com-
Why Ketamine?
pletely. Hence, only rarely will crowing noise alert the
The brain cannot respond to stimuli it does not receive.
anesthesiologist to impending desaturation. Additionally,
Critical concept: GA does not reliably block all incoming
the usual remedy of positive pressure ventilation combined
noxious stimuli! The “wind-up” phenomenon,20 medi-
with anterior jaw thrust is completely ineffective. The anes-
ated by the NMDA receptors, is often invoked to explain
thesiologist must pay particular attention to sneezing or
acute postoperative pain after general anesthesia, as well
coughing as the only prodrome warning him of impend-
as the formation of chronic pain states.
ing laryngospasm.
“Dissociation” refers to a patient who, under the in¬‚u-
The treatment of choice is a rapid IV bolus of lidocaine
1 mg · lb’1 or 2 mg · kg’1 . ence of ketamine, remains motionless in response to noxious
Concern about adding more lidocaine in patients receiv-
Based on clinical observation, the NMDA receptor
ing relatively large amounts of lidocaine local analgesia has
block from a 50 mg dissociative dose of ketamine reli-
led other anesthesiologists to prefer to deepen the propofol
ably blocks all incoming noxious stimuli to the cortex (the
level by adding a 50 mg propofol bolus to break the laryn-
so-called mid-brain spinal) for a period of 10“20 minutes.
gospasm. However, when IV lidocaine has been admin-
After obtaining an equal dissociative effect with a 50 mg
istered for laryngospasm, no stigmata of lidocaine toxic-
ketamine dose in both 90-pound female and 250-pound
ity have been observed. The BIS showed no decrease in
male patients, the author concluded that the number of
response to the IV lidocaine bolus. There was no transient
NMDA receptors does not vary with patient body weight in
hypotension or widening of the EKG complex during the
case. No patient complained of tinnitus, tremulousness,
Preemptive analgesia is most consistently observed
or metallic taste on the tongue after emergence.
when the NMDA receptors are saturated prior to noxious
Administering succinylcholine (SCH) to break the
stimulation. Acetaminophen 1,000 mg po is adequate for
spasm is suboptimal because SCH adds unnecessary (and
postoperative pain management (for the few patients who
avoidable) risk as an MH triggering agent. (Neither propo-
request it) in the context of clonidine-premedicated, BIS-
fol nor ketamine are MH triggering agents.) Further, the
monitored PK MAC patients.12 (See Table 1-5.)
myalgias associated with SCH make the agent totally unac-
ceptable in the elective cosmetic surgery patient.
Making Ketamine Predictable
Waiting until desaturation occurs after the prodrome
will add a substantial amount of time until the lido- In other contexts, ketamine has a well-deserved reputa-
caine can circulate to anesthetize (and open) the vocal tion for causing hypertension, tachycardia, and an unpre-
cords. Desaturation increases the physiologic stress to the dictable 20% of patients experiencing hallucinations or
dsyphorias.21 Hypnotic doses of propofol block ketamine-
patient. The alarm of the pulse oximeter, accompanied
by the bluish discoloration of the patient, increases the induced hallucinations as well as undesirable hemody-
namic sequellae.22 Being able to assign a numerical value
psychological stress to the anesthesiologist, surgeon, and
6 Barry L. Friedberg

Table 1-5. Ketamine tips Table 1-6. Clinical pathway for MIA„ technique

1. 80% patients achieve dissociative effect with 1. Clonidine 0.2 mg PO 30“60 min preop
25 mg ketamine, 98% with 50 mg ketamine. (Systolic >100, body weight >100 pounds).
No “down side” to 50 mg dose as long as BIS 2. Glycopyrrolate 0.2 mg IV with 2 ccs 1% lidocaine
<75. Wait 2“3 min. before injecting local. Wait plain.
an additional min. if patient is reactive before 3. Incrementally titrate propofol to BIS <75 with
multiple, sequential 150 ug · kg’1 · 20 sec.
administering more ketamine.
2. Preemptive analgesia effect is variable when mini-boluses. N.B. If pump does not have a
bolus feature, set initial rate to 450 ug · kg’1 ·
inadequate dissociative effect is obtained.
min’1 and reduce the rate toward 50 as soon
Saturate NMDA receptors!
3. All adult patients, independent of body weight, as the EMG begins to decrease.
Basal propofol infusion rate 50 ug · kg’1 · min’1 .
require 50 mg ketamine initial dose to 4.
saturate NMDA receptors. 5. Ketamine 50 mg IVP @ BIS <75 2“3 minutes
4. Reinjection of previously injected ¬eld does prior to injection local anesthesia.
NOT require more ketamine. 6. Adjust basal propofol rate upward to maintain
5. Consider injecting both sides with initial BIS 60“75 if ketamine causes an increase.
ketamine dose. 7. Inject adequate local analgesia.
6. If prep. is cold, consider injecting 25 mg 8. Administer more ketamine only after two
ketamine 2“3 min. before prep. or consider reinjections of the ¬eld fail to eliminate patient
warming prep. solution! movement.
7. With experience, less ketamine is administered. 9. Maintain propofol at BIS 60“75, EMG 0 on BIS
Friedberg™s case log of the last 500 cases (of scale, 30 on EMG scale.
2,683 patients) showed 80% performed with 10. Bupivicaine in ¬eld before closure, especially for
either one or two 50 mg doses of ketamine.12 browlift, subpectoral breast augmentation,
Mixing propofol with ketamine is TIVA23 not and abdominoplasty.
9. Do not exceed an aggregate total of 200 mg
10. Do not give ketamine in the last 20“30 minutes
Because the elective cosmetic surgical patient tends to be
of a case.
healthy, cardiac output and redistribution from the brain
tend not to be signi¬cant factors in altering established
brain levels of propofol. However, the nineteenfold inter-
with BIS to the level of propofol hypnosis, prior to admin-
patient variation in propofol hydroxylation may play a
istering the ketamine, was an enormous breakthrough in
signi¬cant role in the ability to maintain a stable level of
making ketamine a predictable agent. Not only could the
propofol in the brain.23 Measuring an individual patient™s
initial ketamine dose be administered without problems,
brain response to propofol with BIS would appear to be a
but also subsequent doses, when needed, could be given
more effective strategy than employing target controlled
with assurance.
infusions (TCI) to achieve speci¬c blood levels of propofol
First, create a stable level of propofol in the brain by
(see Table 1-6).
performing an incremental, not bolus, induction. The
incremental induction maintains spontaneous ventila-
tion, commonly maintains masseter tone, avoids propofol
waste, and is less apt to produce induction hypotension. PK MAC was derived from diazepam ketamine MAC tech-
nique, which was ¬rst published in 1981.19 Vinnik clearly
Incremental propofol induction provides hypnosis with
a minimal physiologic and pharmacologic trespass to the enumerated that only after the patient was soundly asleep
from the diazepam was the ketamine to be administered.19
patient. Lesser trespass increases patient safety.
Lesser trespass increases the probability of maintaining Diazepam hypnosis, followed by ketamine dissociation,
the SpO2 >90% on room air (i.e., room air, spontaneous followed by local anesthetic injection was Vinnik™s clin-
ventilation, or RASV). Key concept: Titrate propofol to BIS ical pathway. Although Guit was the ¬rst to publish the
<75 before giving the ketamine! Do NOT give ketamine at combination of propofol and ketamine, the technique was
described as a total intravenous anesthetic (TIVA).24 TIVA
BIS >75.
Propofol Ketamine with Bispectral Index (BIS) Monitoring 7

strongly implies that the local analgesia injected by the bly (PGA) in December 1998, Friedberg returned with the
surgeon is not essential for the success of the TIVA renewed notion of adding po clonidine as a premedica-
technique. In contradistinction, the surgeon™s local anal- tion. Like Vinnik™s concept of administering sleep doses of
gesia is essential for the success of PK MAC. diazepam to block ketamine hallucinations, clonidine for
Guit™s TIVA technique was unknown to Friedberg in premedication had also been previously reported in the
plastic surgery literature. 27,28
1992 when Friedberg embarked on replacing Vinnik™s
diazepam with propofol. The surgeons quickly com- Inconsistent propofol sparing results were observed
plained about the cost of the propofol and pleaded with 0.1 mg po clonidine. A therapeutic clonidine dose
should be in a range between 2.5“5.0 ug · kg’1 .29 Cloni-
for relief. Friedberg added midazolam in an effort to
reduce the amount of propofol. From March 26, 1992 dine 0.2 mg mg po achieves that range in patients weigh-
through March 26, 1997, the case log Friedberg maintained ing between 95“175 pounds. The higher dose of clonidine
contained patient™s names, dates, surgeons, patient age, provided consistent propofol sparing results and further
re¬nement of BIS-monitored PK MAC.30
gender, weight, surgical procedure(s) (see Table 1-2),
midazolam, propofol, ketamine, and anesthesia times.8 From January 26, 2001 to September 2002, rofecoxib
Propofol rates, mg · min’1 and ug · kg’1 · min’1 , were 50 mg po was added to the clonidine. When the drug
calculated retrospectively. was voluntarily withdrawn from the market, rofecoxib was
If 2 mg midazolam was good, perhaps 4 mg midazo- deleted from the premedication. While the addition of the
lam could be better for propofol-sparing purposes. In the rofecoxib appeared to bene¬t the patient, the deletion of
aforementioned case log, a total of 354 patients received 0 the agent did not appear to increase (the already few) post-
mg midazolam, 316 patients received 2 mg, and another operative patient complaints of discomfort.
303 patients received 4 mg midazolam premedication from At the present time, only clonidine 0.2 mg po (30“60
1992“97. No consistent, incremental relationship could be minutes preoperatively) and glycopyrrolate 0.2 mg with
established in propofol savings between the 0, 2, and 4 mg 2 cc 1% lidocaine IV are given as premedication (see
midazolam groups.8 In June 1997, Friedberg eliminated Table 1-6).
the midazolam from PK MAC.
In September 1997, Oxorn published a very elegant Fluid Management
Level I study con¬rming Friedberg™s uncontrolled, clinical The long-standing teaching that patients who are NPO
experience in 973 patients.25 Oxorn reported that there was after midnight are at least 500“1,000 ccs behind on their
no statistical difference in either induction or maintenance ¬‚uids is not especially relevant for elective cosmetic surgery
doses of propofol between those patients who received patients. As stated earlier, these are by and large essentially
2 mg midazolam premedication and those who received healthy patients who are far different from the debilitated
none.25 However, the unexpected ¬nding was that a statis- ward patients on whom most anesthesia trainees learn
tically signi¬cant threefold number of patients who received about anesthesia. Elective cosmetic surgical patients are
midazolam required pain medication in the PACU.25 not “dry.” Vasodilating anesthetics are no longer being
From July 7, 1997, through December 21, 1998, 268 administered. Lastly, large ¬‚uid shifts and blood loss are
patients received BIS-monitored PK MAC without pre- atypical experiences in most elective cosmetic surgery.
medication, midazolam, or other benzodiazepine. During Other authors have analogized the insult produced by
BIS-monitored propofol hypnosis, there were no patients liposuction to that of a burn injury. However, burn patients
who suffered from hallucinations or a lack of amnesia. This do not have compression garments applied to obliterate
experience led Friedberg to conclude that benzodiazepine the “third space” created by the aspiration of subcutaneous
premedication was super¬‚uous to provide amnesia or to fat.
prevent hallucinations in the presence of BIS monitoring. Fluid replacement regimens based on experience in burn
Some of these patients were included in a subsequent pub- patients areinappropriate for liposuction patients.
lication.26 Especially for cases up to 5,000 ccs of liposuction, ¬‚uid
Patients continued to request premedication to calm replacement should remain modest, that is, not more
them. After attending the New York Postgraduate Assem- than 1,000 ccs. Otherwise, one may risk ¬‚uid overload,
8 Barry L. Friedberg

Table 1-7. MIA„ airway algorithm (assumes Table 1-8. Local anesthesia tips
incremental propofol induction)
1. PDR limit of 500 mg lidocaine with epinephrine
(7 mg · kg’1 ) is outdated and overly
1. Extend and laterally rotate head, one side may
have better gas exchange than the other. conservative. Neither the 2005, 2006 nor the
2. Insert shoulder (not neck) pillow to increase 2007 (print or electronic) editions of PDR have
force of extension. any entry for injectable lidocaine!
3. Insert lubricated nasal airway (#28 FR most 2. 200 ccs of 0.5% lidocaine (1,000 mg) with
commonly). epinephrine is well tolerated and without
4. Insert lubricated LMA (#4 most commonly). sequellae of toxicity
Tumescent or “wetting” solution = 500 mg
5. No ET required: >15 yrs, >3,000 patients; 3.
no opioids, benzodiazepines, or muscle lidocaine, 1 mg epinephrine in 1,000 ccs NSS
relaxants. (Klein) or LR (Hunstead)
5,000 ccs of tumescent solution = 2,500 mg
5. 5,000 ccs of tumescent solution in a 60 kg
female patient = 42 mg · kg’1
pulmonary edema, and dilution of platelets and other 6. Avoid >50 cc 0.25% (125 mg) bupivicaine for
coagulation factors. postoperative analgesia.
Another unaesthetic consequence of 2,000“4,000 ccs
¬‚uid replacement in this patient population is enuresis on
the operating room table. This will embarrass the patient
can be educated to inject more analgesia. In addition to
and annoy the nurse who had to clean it up. Catheterizing
the initial injection of the local analgesia, the patient is
the patient to compensate for inappropriate ¬‚uid admin-
spared noxious, painful input during the surgery. The
istration exposes the patient to the risk of an unnecessary
brain cannot respond to stimuli it does not receive. Post-
bladder infection.
operative pain management begins intraoperatively! Repro-
Patients who experience caffeine withdrawal headache
ducible preemptive analgesia occurs under conditions of
without their morning caffeine are encouraged to drink
adequate dissociation secondary to the saturation of the
their cup of coffee black or with non-dairy creamer, if
NMDA receptors. (See Table 1-5.)
necessary. Apple juice or water is permitted up until an
hour before surgery. Patients who are hungry upon awak-
ening are encouraged to have toast and jam. Simple carbo- BIS as Fianchetto
hydrates and sugars are rapidly absorbed by the stomach From Italian, ¬anchetto is a chess term meaning a “dou-
and pose no real threat to patient safety. It is far better to ble move.” In a “binary” system of anesthesia (hypnosis
have the patient arrive without hypoglycemia. Patients are + analgesia = anesthesia), being able to measure hypno-
encouraged to void before getting on the operating table. sis permits an inference about the adequacy of analgesia.
(See Table 1-7.) Adequate analgesia produces de facto muscle relaxation
for minimally invasive surgery. BIS 60“75 with EMG = 0
(on the BIS scale, 30 on the EMG scale) de¬nes adequate
Major Confounding Principle
hypnosis for the MIA„ technique. Therefore, adequate
A blanched surgical ¬eld does not guarantee adequate sur-
hypnosis in the presence of patient movement (usually
gical analgesia. More local analgesia resolves the patient
preceded by a spike in EMG) infers inadequate analgesia!
movement 99% of the time. Administer more ketamine
only after two reinjections of the ¬eld fail to eliminate
Postoperative Pain Management
patient movement.
BIS becomes much more than a simple tool with which In the context of clonidine-premedicated, BIS-monitored
to titrate propofol. BIS becomes a case management tool. PK MAC, now formally known as the MIA„ technique,
By being able to demonstrate adequate propofol levels postoperative pain is minimal to nonexistent. Part of this
(i.e., BIS 60“75) during patient movement, the surgeon phenomenon may be explained by having patients emerge
Propofol Ketamine with Bispectral Index (BIS) Monitoring 9

from propofol with the clonidine still in effect. Patients
Table 1-9. Errors to avoid
who have lower anxiety levels, secondary to lowered
catecholamines from the clonidine, tend to have less pain 1. Ketamine before propofol: NO
2. Ketamine at BIS >75: NO
complaints. In the diethyl ether era, “stormy induction,
3. Bolus propofol induction: NO
stormy emergence” was the common rationale for pre-
4. Inadequate local analgesia: NO
medicating surgical patients. Preoperatively, a clonidine- BIS as ¬anchetto for adequate propofol and
premedicated patient may not appear drowsy but, upon lidocaine
5. Opioids instead of more lidocaine: NO
questioning, usually admits to feeling “calmer.” A fur-
6. Ketamine instead of more lidocaine: NO
ther explanation for the remainder of the observation of
7. >200 mg total ketamine or any in last 20 min. of
minimal-to-no postoperative pain appears to be the phe- case: NO
nomenon of preemptive analgesia. 8. Tracheostomize patient for laryngospasm
instead of IV lidocaine: NO
With the dissociative effect of ketamine, no noxious
9. SCH instead of lidocaine for laryngospasm: NO
signals reach the cortex during the injection of local anes-
thesia. GA does NOT reliably block all incoming noxious
stimuli. Use the BIS to not only maintain hypnosis at
60“75 but also to assure inadequate local analgesia is dealt r
is added to the 1,000 mg acetaminophen (Tylenol P. M. ).
with appropriately (i.e., more local) and not by subterfuge
More experience with the MIA„ technique will elimi-
(i.e., more ketamine, propofol, or opioids). Lastly, bupivi-
nate most of the patient movement seen with inadequate
caine, especially for browlift, breast augmentation, and
local analgesia. These patients may require ketorolac 30“
abdominoplasty, provides long-lasting nonopioid relief.
60 mg IV to deal with “peripheral” pain issues. As the
Do not exceed a total of 125 mg bupivicaine (or 50 ccs
surgeon becomes more willing to inject additional local
0.25%) for postoperative analgesia. Because the bupivi-
analgesia during the case when patient movement occurs
caine quickly binds to tissue, it is necessary only to splash
at BIS 60“75, fewer issues of “peripheral” pain will be
it into the operative ¬eld. Some surgeons prefer to close the
manifest. None of the more than 3,000 PK MAC patients
wound and inject the bupivicaine retrograde up the suc-
has ever required hospital admission for intractable pain.
tion drainage tube(s). Both approaches with bupivicaine
(See Table 1-9.)
are effective.
All of the anesthesiologists™ efforts to prevent PONV
and effect adequate pain management may be for naught
if the surgeon discharges the patient home with an opioid-
r r
containing analgesic (i.e., Vicodin or Tylenol #3 ). One must empathize with those who, understandably,
Darvocet or other similar nonopioid analgesics may have dif¬culty believing that a subpectoral breast aug-
provide an increment of relief greater than 1,000 mg mentation in combination with a classical abdomino-
acetaminophen every six hours. Oral diazepam is espe- plasty can be performed as an of¬ce-based or day surgery
cially effective for decreasing the muscle spasm associated without PONV or postoperative pain management issues.
in subpectoral breast implant patients. N.B. This is also “Cognitive dissonance” is the psychological principle that
a useful strategy for any other submuscular implants; i.e., precludes individuals from believing what they observe
gluteal. when it sharply contradicts what they have been taught to
The few patients who do complain of pain present a dif- believe.
ferential diagnosis of “central” (or supratentorial) versus The On-Q pump may have some additional value;
“peripheral” (infratentorial) pain. Both complaints are real. but in the context described in this chapter, it offers little
Some patients may complain of pain when they had been pain management bene¬t to offset the additional $280 cost
predominantly immobile for the surgery. This pain is more (in 2005 dollars). While dexmedetomidine may possess 8
likely to be “central” in origin. This type of patient may times the alpha2 agonist potency of clonidine, it is 400
respond better if 50 mg po diphenhydramine (Benadryl ) times more expensive (2005 dollars) and more tedious to
10 Barry L. Friedberg

administer. There are no current plans to replace clonidine 10. Flaishon R, Windsor A, Sigl J, et al.: Recovery of con-
sciousness after thiopental or propofol. Anesthesiol 86:613,
with dexmedetomidine in the MIA„ technique.
The MIA„ technique reproducibly provides preemp- 11. www.aspectms.com/resources/bibliographies
tive analgesia and is not technically dif¬cult to execute. It 12. Friedberg BL: Propofol ketamine anesthesia for cosmetic
surgery in the of¬ce suite, chapter in Osborne I (ed.), Anes-
does, however, require the active cooperation of the sur-
thesia for Outside the Operating Room. International Anesthe-
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siology Clinics. Baltimore, Lippincott, Williams & Wilkins,
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14. Kersssens C, Sebel P: Relationship between hypnotic depth
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Aesth Plast Surg 23:70,1999.
Analg 85:553,1997.
9. Lofsky AS: Deep venous thrombosis and pulmonary
26. Friedberg BL, Sigl JC: Bispectral (BIS) index monitoring
embolism in plastic surgery of¬ce procedures. The Doctors™
decreases propofol usage in propofol-ketamine of¬ce based
Company Newsletter. Napa, CA, 2005. www.thedoctors.com/
anesthesia. Anesth Analg 88:S54,1999.
Propofol Ketamine with Bispectral Index (BIS) Monitoring 11

Moderate Sedation/Analgesia
27. Man D: Premedication with oral clonidine for facial
rhytidectomy. Plast Reconstr Surg 94:214,1994. (“Conscious Sedation”)
28. Baker TM, Stuzin JM, Baker TJ, et al.: What™s new in aesthetic
Moderate sedation/analgesia is a drug-induced depression
surgery? Clin Plast Surg 23:16,1996.
of consciousness during which patients respond purpose-
29. Goyagi T, Tanaka M, Nishikawa T: Oral clonidine pre-
fully to verbal commands, either alone or accompanied by
medication reduces awakening concentrations of iso¬‚urane.
Anesth Analg 86:410,1998. light tactile stimulation. No interventions (Editor™s note:
30. Friedberg BL, Sigl JC: Clonidine premedication decreases
“intervention” is unde¬ned.”BLF ) are required to main-
propofol consumption during bispectral (BIS) index moni-
tain a patent airway, and spontaneous ventilation is ade-
tored propofol-ketamine technique for of¬ce based surgery.
quate. Cardiovascular function is usually maintained.
Dermatol Surg 26:848,2000.
N.B. A second physician is involved in: Deep sedation
Deep Sedation/Analgesia
Monitored anesthesia care (MAC) is a term created to
Deep sedation/analgesia is a drug-induced depression of
include all anesthesia services except general or regional
consciousness during which patients cannot be easily
anesthesia. MAC is not especially useful to describe a par-
aroused but respond purposefully following repeated or
ticular anesthetic state or spectrum of states. MAC remains
painful stimulation. The ability to independently main-
a term of exclusion in that it speci¬cally is NOT general or
tain ventilatory function may be impaired. Patients may
regional anesthesia.
require assistance (Editor™s note: “assistance” is unde¬ned.
PK MAC connotes separately administering ketamine
-BLF) in maintaining a patent airway, and spontaneous
after inducing the patient with a continuous infusion of
ventilation may be inadequate. Cardiovascular function
propofol.1 The MIA„ technique adds the layer of BIS
is usually maintained. Re¬‚ex withdrawal from a painful
monitoring along with po clonidine premedication and
stimulus is NOT considered a purposeful response.
infusion pump administered propofol.2
BIS-monitored PK MAC or the MIA„ technique falls
well within the scope of the de¬nition of IV sedation for an General Anesthesia (GA)
AAAASF Class B facility, except in the (current) regulations General anesthesia is a drug-induced loss of consciousness
of the AAAASF and the state of Florida. The MIA„ tech- during which patients are not arousable, even by painful
nique provides a measure of the level of hypnosis achieved. stimulation. The ability to independently maintain venti-
The MIA„ technique intensi¬es but does not depress the latory function is often impaired. Patients often require
laryngeal or “life-preserving” re¬‚exes. assistance in maintaining a patent airway, and positive
pressure ventilation may be required because of depressed
spontaneous ventilation or drug-induced depression of
neuromuscular function. Cardiovascular function may be
Minimal sedation (Anxiolysis) Because sedation is a continuum, it is not always possible
Minimal sedation is a drug-induced state during which to predict how an individual patient will respond. Hence,
patients respond normally to verbal commands. Although practitioners intending to produce a given level of seda-
cognitive function and coordination may be impaired, tion should be able to rescue patients whose level of seda-
ventilatory and cardiovascular functions are unaffected. tion becomes deeper than initially intended. Individuals
administering moderate (“conscious”) sedation/analgesia
should be able to rescue patients who enter a state of deep
— Excerpted from ASA position on Monitored Anesthesia Care in ASA
manual for Anesthesia Departmental Organization and Management, sedation/analgesia, while those administering deep seda-
2003“4. Reprinted with written permission of the American Society
tion/analgesia should be able to rescue patients who enter
of Anesthesiologists. A copy of the full text can be obtained from ASA,
a state of general anesthesia.
520 N. Northwest Highway, Park Ridge, Illinois 60068-2573.
12 Barry L. Friedberg


Neither the term “intervention” (for “conscious” or mod-
erate sedation) nor “assistance” (for deep sedation) to
maintain an airway is de¬ned in the preceding ASA posi-
tion paper.
“Intervention” for “conscious” or moderate sedation may
be any passive maneuver to maintain airway patency. “Inter-
ventions” include, but are not limited to, extending the
head with or without lateral rotation, and placement of a
one liter bag (or similar device) under the patient™s shoul-
ders. “Interventions” are designed to exert more force on
the genioglossus muscle, elevating the tongue off the back
Figure 1-1. The patient is prepared for a rhinoplasty, is asleep
of the oropharynx, and opening the airway. (The genioglos- at BIS 78, spontaneously breathing room air through an LMA.
SpO2 > 96%.
sus muscle is so named because it connects the “genu,” or
“knee,” of the mandible to the “glossus,” or tongue.)
An intermediate maneuver between “intervention” and
r r
(COPA ), laryngeal mask airways (LMA ), and even
“assistance” is sometimes referred to as a “chinner” in the
dental and oral surgical community. A “chinner” is the
Propofol administered at an infusion rate suf¬cient to
manual support of the chin to open the airway long enough
produce a BIS 60“75 (moderate to deep sedation) will
for drug levels to decrease enough to allow the patient
depress the pharyngeal re¬‚exes and inhibit swallowing (see
to regain an adequate SpO2 . By de¬nition, a “chinner” is
Table 4-2). The pharyngeal re¬‚exes are not “life preserv-
a transient maneuver as opposed to either a continuous
ing” because they do not protect the glottic chink.
passive “intervention” or an active “assistance.”
If the patient maintains a preinsertion BIS value of
“Assistance” for deep sedation may be any supraglottic
60“75 after the insertion of a supraglottic device (mean-
mechanical device actively inserted into the nose or mouth
ing that a deeper level of anesthesia was neither required
to maintain airway patency. Examples of such devices are
for the insertion nor maintenance), then the insertion of a
nasal airways, oral airways, cuffed oropharyngeal airways

Figure 1-2. The BIS trace for the entire case. Note that at no time during the LMA insertion or the majority of the case does the patient
require BIS 45“60 (hypnosis compatible with GA) to tolerate her LMA. Clearly, the insertion of an LMA per se does not transform PK
MC/MIA„ technique from a sedation to general anesthesia!
Propofol Ketamine with Bispectral Index (BIS) Monitoring 13

supraglottic device, per se, does not transform a deep seda- with intermittent ketamine may be either moderate or
tion case into a general anesthetic! LMA does not equal GA! 3 “conscious” sedation (BIS 70-78) or deep sedation (BIS
See Figures 1-1 and 1-2. 60“70) depending on whether passive “intervention” or
Modi¬cation of the AAAASF classi¬cation to include active “assistance” for airway maintenance is required (vide
either a separate level or subsection of Level C should be supra).
created to account for nontriggering anesthesia. The MIA„ technique may be classi¬ed as minimal (BIS
A Class C facility typically must have an anesthesia 78“85), moderate “conscious” sedation (BIS 70“78), or
machine, scavenging, and dantrolene to safely provide gen- deep sedation (BIS 60“70), depending on whether a pas-
eral anesthesia. The MIA„ technique is a nontriggering sive intervention (moderate sedation) or an active assis-
technique. Therefore, no increment in patient safety (i.e., tance (deep sedation) is required to maintain the airway.
substantial cost-zero bene¬t) will be achieved by require- The insertion of an LMA without increasing the depth of
ments that ignore the value of measuring the patient™s level anesthesia below BIS 60“75 does not transform a sedation
of consciousness. Intravenous sedation can be minimal, case into a general anesthesia. The MIA„ technique is MAC,
moderate, or deep sedation as well as general anesthesia not GA or TIVA. The MIA„ technique does not require
an anesthesia machine,21 scavenging, or dantrolene to be
(vide supra).
In an attempt to bring a semblance of order into the safe, simple reproducible, and effective for patients having
chaotic nomenclature of levels of sedation/anesthesia, ill elective of¬ce-based cosmetic surgeries.
the ASA has de¬ned four speci¬c clinical levels. The Numerical terminology is more precise than verbal ter-
attempt to differentiate “conscious sedation” as being per- minology to describe levels of sedation and anesthesia.
formed by a single physician would appear to preclude Numerical terminology permits more precise and effec-
the possibility of “conscious sedation” being provided tive communication of the level of hypnosis and analgesia
by a second physician (i.e., an anesthesiologist or nurse between the anesthesiologist and his surgeons as well as
anesthetist). This is incompatible with current clinical his fellow anesthesiologists.
All of the ¬rst three levels of sedation may be described
MAC because they are neither general nor regional anesthe-

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