Anesthesia Awareness

[Cheisu]

How do you guys feel about the topic?

I think there needs to be some measure initiated to prevent this occurrence.

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[gasnewby]

this kid's a 16 year old high school student who posts on the surgery forum...

 

[BlackSails]

How do you guys feel about the topic?

I think there needs to be some measure initiated to prevent this occurrence.

I believe the usual measure is called "Anesthesia."

 

[aghast1]

‘AWAKE’ the movie highlights the need for ‘Goldilocks’ anesthesia, says developer of bispectral index (BIS) monitored propofol ketamine sedation, now trademarked as minimally invasive anesthesia(MIA)®.

Those interested in the body of this press release are welcome to view it gratis @www.cosmeticsurgeryanesthesia.com on Wednesday November 28, 2007.

Warm regards from sunny Southern California,

aghast1

 

[swpm]

[...]

Oh God, give it a rest already, OK? This is approaching the level of spam.

 

[coprolalia]

Bi-spectral index monitoring does not guarantee lack of awareness during anesthesia. Period.

-copro

 

[BLADEMDA]

Bi-spectral index monitoring does not guarantee lack of awareness during anesthesia. Period.

-copro

Did you see the question/answer in the 2007 ASA CME booklet? It showed a dolphin with TWO Bis strips across its forehead attached to two separate but identical BIS monitors. Guess what they displayed? Two completely different BIS readings at least 10 apart from each other.

BIS is huge marketing tool but in no way replaces common sense and vigilance. In fact, the most important thing a provider can do to avoid awareness is CHECK the end tidal gas reading on his/her monitor! You need to make certain that a MINIMUM of 1/2 MAC VAPOR agent is being expired at all times especially at the start of the case. Thus, OVERDRIVE the vaporizer and monitor the exhaled vapor prior to cutting back on the gas. Now, obviously this strategy is best reserved for your healthy ASA 1 or 2 patient and NOT the 80 year old ASA 4 who won't remember anything (and probably couldn't pre-op either) for days.

Blade

 

[aghast1]

Did you see the question/answer in the 2007 ASA CME booklet? It showed a dolphin with TWO Bis strips across its forehead attached to two separate but identical BIS monitors. Guess what they displayed? Two completely different BIS readings at least 10 apart from each other.

BIS is huge marketing tool but in no way replaces common sense and vigilance. In fact, the most important thing a provider can do to avoid awareness is CHECK the end tidal gas reading on his/her monitor! You need to make certain that a MINIMUM of 1/2 MAC VAPOR agent is being expired at all times especially at the start of the case. Thus, OVERDRIVE the vaporizer and monitor the exhaled vapor prior to cutting back on the gas. Now, obviously this strategy is best reserved for your healthy ASA 1 or 2 patient and NOT the 80 year old ASA 4 who won't remember anything (and probably couldn't pre-op either) for days.

Blade

"...common sense..."

Voltaire claimed that common sense was not common.

Why would you not want to know how your drugs may be affecting the target organ, the brain? We are not trying to anesthetize the BP and HR.
Trends in HR & BP are notoriously unreliable signs of depth of anesthesia.

Very impressed both of you can ignore 3,000+ scientific publications validating the technology. I am but a simple clinician. Those dudes who published all those papers are real, honest-to-goodness scientists!

If you want to anesthetize dolphins, go right ahead.

"BIS is huge marketing tool but in no way replaces common sense and vigilance. "

Wherever did you get the idea that it did? Could you quote this concept, please.

"In fact, the most important thing a provider can do to avoid awareness is CHECK the end tidal gas reading on his/her monitor! "

Mmmmm, I may have a problem with my propofol drip's 'end tidal reading.'

Haven't used toxic, stinky gases for 15 years. No justification for their avoidable risks in elective cosmetic surgery. Massive overkill for the assignment.

GA for cosmetic surgery is like fornicating for chastity - it may feel good at the time but ultimately it fails to deliver optimal patient safety and outcomes.

Don't know anything that can prevent awareness but BiS monitoring will reduce its incidence by 82%.

Much preferable to avoid routinely paralyzing patient who really don't require relaxants in the first place, esp. cosmetic surgery pts. Then, at least, you can have spinal cord reflex movement to let you know something may be amiss.

"Now, obviously this strategy is best reserved for your healthy ASA 1 or 2 patient and NOT the 80 year old ASA 4 who won't remember anything (and probably couldn't pre-op either) for days."

Ever heard the term 'postoperative cognitive dysfunction (POCD)? Some think it may be related to routinely overdosing patients; i.e. BIS <45. Does the 'end tidal' help you here?

What? No 'black box' argument?

Warm regards from SoCal,

aghast1

 

[coprolalia]

Why would you not want to know how your drugs may be affecting the target organ, the brain?

The "brain" - specifically one hemisphere of the frontal lobe, which is what BIS analyzes - is the target organ? Is it even the primary target? You might need a little more CME if you still believe this is the case... We all recognize you've been out of residency a long time... Your knowledge gaps are starting to show...

-copro

 

[Arch Guillotti]

‘AWAKE’ the movie highlights the need for ‘Goldilocks’ anesthesia, says developer of bispectral index (BIS) monitored propofol ketamine sedation, now trademarked as minimally invasive anesthesia(MIA)®.

Those interested in the body of this press release are welcome to view it gratis @www.cosmeticsurgeryanesthesia.com on Wednesday November 28, 2007.

Warm regards from sunny Southern California,

aghast1

Dude enough of the spam.

 

[aghast1]

The "brain" - specifically one hemisphere of the frontal lobe, which is what BIS analyzes - is the target organ? Is it even the primary target? You might need a little more CME if you still believe this is the case... We all recognize you've been out of residency a long time... Your knowledge gaps are starting to show...

-copro

I'll take one hemisphere over HR & BP trends any day, dude.thumbdown

aghast1

 

[coprolalia]

I'll take one hemisphere over HR & BP trends any day, dude.thumbdown

aghast1

"Dude", you don't even know the primary site of action of the drugs you're delivering.

-copro

 

[BLADEMDA]

"Real World" Awareness is 1:15,000 and NOT 0.2%. TIVA anesthetics are indeed popular for outpatient/plastic surgey cases but in no way does that mean BIS is "essential" to reduce awareness. Instead, the use of LMA and/or limiting muscle relaxants ensures that the horror story like the movie "AWAKE" never occurs.

In my opinion, and it is just that, awareness under aneshesia is likely due to provider error or faulty equipment the vast majority of the time. I work in a practice where more than 300,000 anesthetics have been given during my career.
Outside of MAC Cases I know of only one awareness case and I believe the provider had an empty vaporizer!

BIS is available at my Institution and is used for about 5% of cases. In particular, all Cardiac cases get a BIS. As for "goldilocks" anesthesia that is more theory than fact.

BIS is a monitoring "tool" with limitations. Like the movie JAWS the movie AWAKE is more about fear than reality. Don't buy into the fear; instead look at the facts 1 in 15,000!

Blade

 

[aghast1]

"Dude", you don't even know the primary site of action of the drugs you're delivering.

-copro

let's be frank einstein, tell the girls and boys where the primary site of action is

even at my age and advanced condition i am willing to learn something from such a bright light as yourself

dont know if i can contain my anticipation at the enlightenment to come, but i will try


have a wonderful day

aghast1

ps bis is a cortical monitor
bis tracks my pts propofol levels
i will bet on the cerebral cortex'
can 3,000+ scientific papers all be wrong

 

[Planktonmd]

let's be frank einstein, tell the girls and boys where the primary site of action is

even at my age and advanced condition i am willing to learn something from such a bright light as yourself

dont know if i can contain my anticipation at the enlightenment to come, but i will try


have a wonderful day

aghast1

ps bis is a cortical monitor
bis tracks my pts propofol levels
i will bet on the cerebral cortex'
can 3,000+ scientific papers all be wrong

Ok,
I actually think your technique of Propofol + Ketamine is elegant and if BIS monitoring adds to it's elegance so be it.
Now, can we now move on?
You are a senior anesthesiologist with 30 years experience and I am sure all of us can benefit from your contribution to this forum on other subjects.

 

[aghast1]

"Real World" Awareness is 1:15,000 and NOT 0.2%. TIVA anesthetics are indeed popular for outpatient/plastic surgey cases but in no way does that mean BIS is "essential" to reduce awareness. Instead, the use of LMA and/or limiting muscle relaxants ensures that the horror story like the movie "AWAKE" never occurs.

In my opinion, and it is just that, awareness under anesthesia is likely due to provider error or faulty equipment the vast majority of the time. I work in a practice where more than 300,000 anesthetics have been given during my career.
Outside of MAC Cases I know of only one awareness case and I believe the provider had an empty vaporizer!

BIS is available at my Institution and is used for about 5% of cases. In particular, all Cardiac cases get a BIS. As for "goldilocks" anesthesia that is more theory than fact.

BIS is a monitoring "tool" with limitations. Like the movie JAWS the movie AWAKE is more about fear than reality. Don't buy into the fear; instead look at the facts 1 in 15,000!

Blade

"TIVA anesthetics are indeed popular for outpatient/plastic surgey cases but in no way does that mean BIS is "essential" to reduce awareness."

A dull blade cuts nothing [flame] Botero CA, Smith CE, Holbrook C, et al.: Total intravenous anesthesia with a propofol-ketamine combination during coronary artery surgery. Journal of Cardiothoracic Vascular Anesthesia 14:409,2000.

BIS monitored propofol ketamine (or minimally invasive anesthesia®) @ 60-75 is moderate to deep sedation requiring adequate local anesthesia for success. This is MAC - not TIVA or GA

TIVA - total intravenous anesthesia implies that the surgeon's local is not essential for the success of the technique.

Let me say this again s-l-o-w-l-y, MAC requires adequate local analgesia, TIVA does not. MAC is everything that cannot be classified as GA, SAB, epidural, or nerve block. MAC is a stupid billing term (formerly called 'local with standby' for the history buffs out there*) that implies some anesthesia care is NOT monitored, but we are not talking about surgeon administered anesthesia.If one is administering systemic analgesics instead of relying on adequate local analgesia, then the technique is an IV GA regardless of the BIS level.

Some may feel that my 50 mg dissociative dose of ketamine constitutes a systemic analgesic. It may well for the 10-20 minutes it is effective but one cannot perform a 2-3 hour case without adequate local after the ketamine is no longer effective.

Those who mix the ketamine with the propofol are following Guit's published paradigm, not mine.

Again, if you need to call my technique GA to get paid, go right ahead with my blessing. If you want to know if it is MAC or TIVA, I say it is MAC and have published so numerous times, even in peer reviewed journals.

I cannot speak for other anesthesiologists, but I have repeatedly posted here ( & elsewhere) that, since none of my patients are paralyzed, the awareness issue was NEVER a concern of mine.

I was attracted to BIS monitoring as a means to more efficiently administer propofol, thereby saving my surgeons some money. In 1997, Zeneca was making about $1/3 billion a year on North American Diprivan® sales.

What was "essential to reduce" was the cost of the Diprivan®.

" BIS is available at my Institution and is used for about 5% of cases. In particular, all Cardiac cases get a BIS. "

I would hazard a guess that none of the BIS monitored cases trend EMG as a secondary trace.

No, EMG is not perfect but it is instantaneous. BIS lags 15-30 seconds behind real time and is of limited value for adjusting medication doses.

I would even hazard a second guess that you would never even consider trying it so you could report to the forum.

" BIS is a monitoring "tool" with limitations."

Does that mean you believe every BP from the NIABP, every SpO2 from the pulse ox, and every rhythm perturbation from the EKG?

Everything "tool" we use in the OR has its limitations but at 5% usage, your institution has barely scratched the surface of what it could be teaching the young lights.

"As for "goldilocks" anesthesia that is more theory than fact."

Since I am only a volunteer assistant professor, I am confident you must outrank me. Nonetheless, I will be brave enough to disagree agreeably.

Propofol titrated @ 60>BIS>75 is not a theory but a well established fact: not too much and not too little but just right for my work in cosmetic surgery.

This is my practice everyday I go to work. The fact that I am fortunate enough not to have to work every day does not detract from the fact.

"Don't buy into the fear; instead look at the facts 1 in 15,000!"

If you didn't like your mother in the first place, you probably would mind if she was that 1 in 15,000 patients. How about if it was you?

BIS does not eliminate the need for vigilance or our vital signs monitors. BIS gives us information we cannot get from any other source.

It took me 2 years of routinely using the BIS to stop keying on HR & BP trends and respond to EMG spikes instead. I admit to being a slow learner.
Two years of training ('75-'77) and 20 years practicing that HR & BP trends tell me something about the patient's depth of anesthesia. Hogwash.

On more thing about my 15 year exclusively office based anesthesia experience:

Unlike an institution,

THERE IS NO PLACE TO HIDE FROM YOUR OUTCOMES!

My patients will complain if something as 'trivial' as an uncomfortable IV start occurred. They will not hesitate to notify the surgeon and his staff if they barf.

(FWIW, a 25G needle is not a 'small' needle to the skin wheal before the IV. A 30G is small and a 32 is equivalent to an acupuncture needle. It is not nice to hurt a cosmetic surgery patient. maybe even good for 'real' patients, too.)

My practice is a high risk practice as defined by Christian Apfel:

Non-smoking females with histories positive for PONV having emetogenic cosmetic surgery of 2 or more hours duration.

Multimodal therapy is advised for this high risk group.

MIA has published PONV rates of 0.5-0.6% without antiemetics.

Must be a reason Apfel cites Propofol-ketamine technique, dissociative anesthesia for office surgery: a five year review of 1264 cases. (article) Aesthetic Plastic Surgery 23:70,1999 as an example of what happens to PONV rates when the anesthetic technique avoids opioids and stinky gases.

Go ahead, tell me the anesthesiologist who published in NEJM doesn't know what he is talking about.

Yours for better & reproducible outcomes,

aghast1

*History 101 - OK, professor, please tell us what anesthesiologist was responsible for creating the anesthetic record we use every day. Hint: great bar bet similar to the name of the president on the $100 bill.

 

[aghast1]

Ok,
I actually think your technique of Propofol + Ketamine is elegant and if BIS monitoring adds to it's elegance so be it.
Now, can we now move on?
You are a senior anesthesiologist with 30 years experience and I am sure all of us can benefit from your contribution to this forum on other subjects.

When one spends some of their clinical time in a specific field, we refer to them as sub-specialist, like cardiac, neuro, ortho, ob, etc.

When, as Dr. Robert Kotler, author of Secrets of a Beverly Hills Cosmetic Surgeon, one spends all of his time in one area, we can call him a super-specialist. That would be him in cosmetic surgery and me in cosmetic surgery anesthesia.

I am the first to admit I am not a scientist, never claimed to be one. Just a clinician (almost as pejorative a word as 'LMD!'). I have performed jusst one anesthetic technique (propofol ketamine a la Vinnik's diazepam ketamine paradigm) for the entire last 15 years, the last 10 with the BIS monitor.

I have attempted to lend my knowledge to the group of students because I am concerned they may not otherwise be exposed to this very useful paradigm.

My office based anesthesia career began with a tragedy in 1990 in my little beach town. An otherwise healthy 34 yo WF came to a plastic surgeon's office for a breast aug. She died a week later from an avoidable anoxic insult. A totally avoidable death.

My book was launched after the demise of Olivia Goldsmith of The First Wives' Club fame. Another avoidable death.

The recent death of rapper Kanye West's mother was another avoidable death, likely due to excess Vicodin.

The routine use of techniques that do not provide pre-emptive analgesia for cosmetic surgery needs to cease.

At this year's ASA, I learned that none other than Rebecca Twersky has learned the joys of avoiding opioids, and using propofol and ketamine with my paradigm, I feel things may actually change in my lifetime. Dr. Twersky has been a persistent critic of my technique. Now that she has seen the benefits of MIA first hand, my hope is that she will share the technique with her residents.

Also, at this year's ASA, I autographed a copy of my book for Terri Monk at Duke. She said she would go home and play with the technique. If she liked it, she said, she would teach it to her residents.

Finally, Janet Pavlin also expressed interest in my book and technique to teach her residents at U of Wash.

Drs. Rebecca Twersky, Terri Monk, & Janet Pavlin are not trivial players in academic anesthesia.

It is not easy for a volunteer assistant professor to pass along his life's work. It may soon be getting easier.

Best regards,

aghast1

 

[BLADEMDA]

In my experience doing about 50 Breast augmentations with a pure propofol technique and every available anti-emetic combined with tiny doses of narcotic (like 100 micrograms of Fentany) the post-operative Nausea/Vomiting was due to the OXYCODONE or DILAUDID pill prescribed by the plastic surgeon.

In other words, despite a practically perfect anesthetic young female patients are still prone to nausea long after the anesthetic. Since the surgeon continued to prescribe the pain killers for his patients I switched to Sevoflurane and found little difference at 24 hours (all avail. ant-emetics given). The surgeon agreed the techniques were equal in terms of outcome (N/V) and room turn-over (less than 3 minutes).

Until the "big boys" do a large study comparing techniques, outcomes, etc. in a randomized study I will continue to use "stinky" vapor when appropriate.
In addition, the definition of MAC as defined by the ASA is different than yours. Since you get paid "cash $$$$" and don't need to worry about third party payers the wording means little to you. However, for some of us MAC and TIVA are important distinctions for CMS.

Finally, I have been 'put under' several times without BIS and so have my family members. I wouldn't hesitate to use "stinky" vapor on my Mother when appropriate. POCD has not been proven to be altered by any anesthetic technique including a pure propofol one. That said, I do avoid vapor on my borderline/ mild dementia patients when possibe (no good evidence to suppory my decision).

This thread was about "awareness" and NOT your MIA technique. Perhaps, you wouldn't mind going MIA on this thread for a while? After all, you have explained your technique ad-nauseum.

Blade

 

[aghast1]

In my experience doing about 50 Breast augmentations with a pure propofol technique and every available anti-emetic combined with tiny doses of narcotic (like 100 micrograms of Fentany) the post-operative Nausea/Vomiting was due to the OXYCODONE or DILAUDID pill prescribed by the plastic surgeon.

In other words, despite a practically perfect anesthetic young female patients are still prone to nausea long after the anesthetic. Since the surgeon continued to prescribe the pain killers for his patients I switched to Sevoflurane and found little difference at 24 hours (all avail. ant-emetics given). The surgeon agreed the techniques were equal in terms of outcome (N/V) and room turn-over (less than 3 minutes).

Until the "big boys" do a large study comparing techniques, outcomes, etc. in a randomized study I will continue to use "stinky" vapor when appropriate.
In addition, the definition of MAC as defined by the ASA is different than yours. Since you get paid "cash $$$$" and don't need to worry about third party payers the wording means little to you. However, for some of us MAC and TIVA are important distinctions for CMS.

Finally, I have been 'put under' several times without BIS and so have my family members. I wouldn't hesitate to use "stinky" vapor on my Mother when appropriate. POCD has not been proven to be altered by any anesthetic technique including a pure propofol one. That said, I do avoid vapor on my borderline/ mild dementia patients when possibe (no good evidence to suppory my decision).

This thread was about "awareness" and NOT your MIA technique. Perhaps, you wouldn't mind going MIA on this thread for a while? After all, you have explained your technique ad-nauseum.

Blade

Dude,

I do respect your 'extensive' 50 case experience with breast aug.
Table 1-2 in Anesthesia in Cosmetic Surgery Cambridge University Press 2007 lists my 10 year experience with 489 breast augs.
Is it remotely possible that maybe, just maybe, I know something more than you do? Couldn't be. You are an attending. Far out.

I hasten to point out that I make no claim of science. I am a clinician reporting my experience in a very challenging environment where my financial well being is not insulated by a contract, as is yours. You can afford to be indifferent to your outcomes. I cannot.

Guess what? Pay for performance (P4P) may rock your world.

IMHO, 'tiny' doses of fentanyl or any other opioid have no place in a PONV free anesthetic. Why else would you need "every available anti-emetic?" What a waste of resources.

I do recall a conversation with one gasser who, after I was extolling the virtues of minimal trespass, remarked, "Hell, the more drugs I give, the better I feel."

Nice attitude but not for the patient. Remember outcomes not beliefs (vide infra) are supposed to guide our therapy.

If you don't have a good enough relationship with your surgeon to educate him to avoid postop opioids, try harder. They don't want a puke even more than your ego does.

"Until the "big boys" do a large study comparing techniques, outcomes, etc. in a randomized study I will continue to use "stinky" vapor when appropriate."

Please justify the risks of pulmonary embolus, myocardial infarction, wrong site intubation, or malignant hyperrthermia (just to name a few) IN PATIENTS WHO HAVE NO MEDICAL INDICATION FOR SURGERY; i.e cosmetic surgery patients.

There is no risk:benefit for your stinky gases in this patient group. This point has clearly escaped you or you lack the logical framework to understand it.

"Since you get paid "cash $$$$" and don't need to worry about third party payers the wording means little to you."

From post #16, which you obviously are too important to read before sounding off:

Again, if you need to call my technique GA to get paid, go right ahead with my blessing.

"POCD has not been proven to be altered by any anesthetic technique including a pure propofol one. That said, I do avoid vapor on my borderline/ mild dementia patients when possibe (no good evidence to suppory my decision)."

Again, you missed the point about measuring the organ you are medicating - the brain. Duh. Maybe you should re-read Goldilocks again - not too quickly, not too slowly, but just the right speed.

"This thread was about "awareness" and NOT your MIA technique."

Let me say this real s-l-o-w-l-y, one more time:

Minimally invasive anesthesia is BIS monitored propofol ketamine MAC.

The fact that the ASA definition of MAC is different than mine causes me no problem.

The ASA is primarily a political organization involved in securing better third party payment for its members, like you. Any patient benefit benefit from their activity is as incidental as it is accidental.

See Appendix 1-1 Defining Anesthesia Levels - the terminology in Anesthesia in Cosmetic Surgery Cambridge University Press 2007.

Without the ability to measure by how much one is trespassing, one cannot trespass the least necessary to give the patient what they want; i.e. not to hear, feel or remember their anesthetic.

Since BIS has been demonstrated to reduce awareness by 82%, if you are not monitoring it or doing only 5% of the time, you are being cavalier with your patients.

"Finally, I have been 'put under' several times without BIS and so have my family members. I wouldn't hesitate to use "stinky" vapor on my Mother when appropriate."

So what. And your point would be? You and mommy survived despite your anesthetic maybe?

Unresponsive to the question which was: how would you feel if that 1:15,000 awareness happened to you or your mother?

"After all, you have explained your technique ad-nauseum."

Since your breast aug pts. continue to barf and mine don't, let me suggest you have no business using 'ad nauseum.' Again, I am certain you are too smug to even consider another approach to show your residents.

Anyone who can dismiss the work of 3,000 peer revised scientific papers validating the utility of BIS is not going to persuaded by reason.

Your clinical anesthesia behavior is governed by your beliefs and beliefs are not subject to reason.

My outcomes are congruent with my belief system. No stinky gases, no opioids, high risk pts. & an unprecedented 0.5% PONV without ANY anti-emetics. Moreover, those who have followed my paradigm have reproduced my outcomes.

Yours for better & reproducible outcomes,

aghast1

 

[huktonfonix]

Interesting thread. Im always in favor of avoiding opioids when possible but its not always possible especially in an academic environment. I also prefer using the ketamine and propofol separately for a MAC especially in a prolonged procedure. Alternatively I may use prop/ket mix up to 50-100mg then just straight prop after. Of course as you've all mentioned its contingent on the surgeon using adequate local. The clonidine is a nice touch and something I'll have to try in the future, although it is an off label use of clonidine (I will admit a lot of stuff we do is off label though). I'm not sure if I would agree with using a BIS monitor on all of my MAC cases. It just seems to be an extra added expense that may not add much to the outcome. As previously stated a low BIS score may have and association with an increased morbidity/mortality rate, but I dont believe this was done comparing TIVA to inhaled. Now in a system where the patients pay up front in cash (i.e. office plastics), I'm sure the expense of the BIS might be justified but in an already overburdened medical system it may be difficult. I'm also not sure how the surgeons would be able to completely avoid post op narcotics. NSAIDS and local will only get you so far.

 

[aghast1]

Interesting thread. Im always in favor of avoiding opioids when possible but its not always possible especially in an academic environment. I also prefer using the ketamine and propofol separately for a MAC especially in a prolonged procedure. Alternatively I may use prop/ket mix up to 50-100mg then just straight prop after. Of course as you've all mentioned its contingent on the surgeon using adequate local. The clonidine is a nice touch and something I'll have to try in the future, although it is an off label use of clonidine (I will admit a lot of stuff we do is off label though). I'm not sure if I would agree with using a BIS monitor on all of my MAC cases. It just seems to be an extra added expense that may not add much to the outcome. As previously stated a low BIS score may have and association with an increased morbidity/mortality rate, but I dont believe this was done comparing TIVA to inhaled. Now in a system where the patients pay up front in cash (i.e. office plastics), I'm sure the expense of the BIS might be justified but in an already overburdened medical system it may be difficult. I'm also not sure how the surgeons would be able to completely avoid post op narcotics. NSAIDS and local will only get you so far.

"...contingent on the surgeon using adequate local."

On my last foray into the bowels of academia, I approached the surgical residents with the following:

"I am on your side here. I don't want you to have any postop problems with barfing patients or hurting ones. Will you do just a little bit to work with me to eliminate these problems? Just put some local in the field before you cut and if I ask for a little more during the case, please just do it. I am on your side."

Admittedly, not every macho surgical resident will bite on this but it's at least a place to start. This worked very well in this instance.

Believe it or not, they think we don't really care about the patient once we drop them in PAR. Hmmm... wonder where they could have gotten that idea.

As I said in a previous post, the surgeon's dilemma is that he sees a vasoconstricted field and reasons that he should have lidocaine effect when he sees epi effect. Use of the BIS can finesse this issue. The answer is "I don't know why you don't have lido effect in this little area, but I can assure you the patient is getting a good amount of propofol (BIS 60-75).

"The clonidine is a nice touch and something I'll have to try in the future, although it is an off label use of clonidine... "

Old news in the plastic surgery literature.

Man Plast Reconstr Surg 94:214, 1994
Baker Clin Plast Surg 23:16, 1996.

Of course,, so was Vinnik in 1981. Different story but very useful nonetheless.

"I'm not sure if I would agree with using a BIS monitor on all of my MAC cases."

You don't have to. I enjoy it because it adds interest to my day not because of the awareness or one-year morbidity issues. Kind of like an open book test for dosing.

BTW, what it the usual response during MAC when the HR & BP are running along lilke railroad tracks, yet the patient moves? Oh, he was playing possum! With BIS (& EMG as secondary trace) there is no playing possum.

There is a 19 fold inter-individual difference in propofol metabolism. Any dosing scheme based on body weight and vital sign trends is doomed from the outset.

"Now in a system where the patients pay up front in cash (i.e. office plastics), I'm sure the expense of the BIS might be justified but in an already overburdened medical system it may be difficult."

Agreed, difficult but not impossible. I bring my own BIS and pay for my own sensors. Does wonders to reassure the surgeons I am not wasting their propofol.

"I'm also not sure how the surgeons would be able to completely avoid post op narcotics. NSAIDS and local will only get you so far."

Excellent point!Following my paradigm of hypnosis first, then dissociation, you will saturate the NMDA receptors in 98% of adults with your 50 mg ketamine bolus and a 2-3 min wait before injection. This means the cortex receives no input for the injection of local anesthesia, setting the stage for pre-emptive analgesia.

If the patient does not receive noxious input for either the injection or the surgery, then the 'wind-up' phenomenon does not occur. The brain cannot respond to information it does not receive!

Leaving some bupivicaine in the field also helps with postop pain. (N.B. Do not exceed a total of 125 mg or 50 ccs 0.25%, 100 cc. 0.125% or 200 cc 0.0675% bupivicaine).

Pts. receiving this paradigm manage postop pain very nicely with 1,000 mg po Tylenol. I use the Tylenol PM if they have been stiull during surgery but complain of postop pain. Sometimes 30 mg IV ketorolac is needed but not very often.

Glad you have had positive experiences with propofol & ketamine.

Hope these remarks help.

Best wishes for your continued success,

aghast1

 

[BLADEMDA]

The name of this thread is 'Anesthesia Awareness' and not Anesthesia for Cosmetic Surgery.

As for 100 micrograms of Fentanyl causing Nausea 24 hours later where is the logic in that belief? Fenanyl is not in the system that far out to be the cause of Nausea.

My cosmetic experience is much greater than "50" as I was listing the number we evaluated for the Sevo technique vs. Propofol.

There is much more to postoperative Nausea than just the anesthesia technique for Breast Augmentation. That is my point. It takes the right surgeon with avoidance of post-operative narcotics. One person's individual experience with "claims" that are unsubstantiated by peer reviewed literature is suspect at best.

Now, I will stick to the topic on this thread "anesthesia awareness" and hope the moderators will help do the same.

Blade

 

[aghast1]

The name of this thread is 'Anesthesia Awareness' and not Anesthesia for Cosmetic Surgery.

As for 100 micrograms of Fentanyl causing Nausea 24 hours later where is the logic in that belief? Fenanyl is not in the system that far out to be the cause of Nausea.

My cosmetic experience is much greater than "50" as I was listing the number we evaluated for the Sevo technique vs. Propofol.

There is much more to postoperative Nausea than just the anesthesia technique for Breast Augmentation. That is my point. It takes the right surgeon with avoidance of post-operative narcotics. One person's individual experience with "claims" that are unsubstantiated by peer reviewed literature is suspect at best.

Now, I will stick to the topic on this thread "anesthesia awareness" and hope the moderators will help do the same.

Blade

"One person's individual experience with "claims" that are unsubstantiated by peer reviewed literature is suspect at best. "

Published 0.6% PONV ( 7 of 1,264 pts.)

Propofol-ketamine technique, dissociative anesthesia for office surgery: a five year review of 1264 cases. (article) Aesthetic Plastic Surgery* 23:70,1999.

* a peer-reviewed, index medicus journal

in case you were not 'aware'

aghast1

ps thanks for the new thread 'anesthesia in cosmetic surgery'
see you there