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Editorial article
Opioid free anesthesia with BIS/EMG monitored propofol-ketamine
Anestesia libre de opioides con propofol-ketamina monitorizada mediante BIS/EMG
B.L. Friedberg
Presidente y fundador, Goldilocks Anesthesia Foundation, Newport Beach, CA, United States
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In March 1992&#44; work began in a board certified&#44; plastic surgeon&#39;s office that&#44; in 1990&#44; had experienced a fentanyl-related death of an otherwise healthy&#44; postpartum woman for breast augmentation surgery&#46; Understandably&#44; that surgeon forbade use of <span class="elsevierStyleItalic">any</span> opioids for anesthesia&#46; In addition&#44; his office did not perform enough cases to justify the cost of an anesthesia machine&#46; After hearing Vinnik&#39;s diazepam ketamine technique for cosmetic surgery anesthesia&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">1</span></a> 50<span class="elsevierStyleHsp" style=""></span>mg IV ketamine was administered to render patients immobile &#40;i&#46;e&#46; dissociated&#41; for the surgeon&#39;s local anesthesia injection <span class="elsevierStyleItalic">after</span> achieving loss of lid reflex and loss of verbal response with incremental propofol doses&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">2</span></a> Incremental propofol induction also tends to maintain a non-instrumented airway by preserving the tone of the <span class="elsevierStyleItalic">genioglossus</span>&#44; <span class="elsevierStyleItalic">orbicularis oris</span>&#44; <span class="elsevierStyleItalic">masseter</span> &#38; <span class="elsevierStyleItalic">temporalis</span> muscles in addition to spontaneous ventilation&#46; Elective cosmetic surgery patients will complain of a sore throat if their airways have been instrumented&#46; It was a great surprise &#40;and delight&#41; that <span class="elsevierStyleItalic">none</span> of the first 50 patients needed postoperative opioid treatment for pain&#44; experienced PONV&#44; or had hallucinations&#44; dysphorias&#44; flashbacks&#44; hypertension&#44; tachycardia or sore throats&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">3&#44;4</span></a> Hallucination-free ketamine use has remained consistent for the 25 years of this opioid free&#44; office-based cosmetic surgery anesthesia practice for more than 6000 patients&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">5</span></a> In Europe&#44; noted Belgian anesthesiologist&#44; Dr&#46; Jan Mulier and his followers have been using ketamine and other adjuvants for opioid free anesthesia for bariatric and other surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">After June 1997&#44; having found no reduction of propofol dose with either 2 or 4<span class="elsevierStyleHsp" style=""></span>mg midazolam premedication&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">5</span></a> midazolam was omitted from the propofol ketamine paradigm&#46; Glycopyrrolate 0&#46;2<span class="elsevierStyleHsp" style=""></span>mg with 30<span class="elsevierStyleHsp" style=""></span>mg lidocaine IV is used to prevent ketamine secretions and mitigate propofol pain on injection&#46; 50<span class="elsevierStyleHsp" style=""></span>mcg<span class="elsevierStyleHsp" style=""></span>kg<span class="elsevierStyleSup">&#8722;1</span> propofol is given repeatedly until the EMG descends to baseline<a class="elsevierStyleCrossRef" href="#fn0005"><span class="elsevierStyleSup">1</span></a> and the BIS value is &#60;75&#46; See Table 1 The December 1997 addition of the BIS monitor provided a quantitative&#44; <span class="elsevierStyleItalic">numerically reproducible</span> basis<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">7</span></a> for the administration of propofol to provide a level that avoids negative ketamine side effects&#59; i&#46;e&#46; &#60;75 with <span class="elsevierStyleItalic">baseline</span> EMG of the facial <span class="elsevierStyleItalic">frontalis</span> muscle&#44; as real time a signal as is the EKG of the cardiac muscle&#46; EMG signals persist in the presence of Botox or neuromuscular blocking &#40;NMB&#41; agents&#46; NMB use has never been part of the propofol-ketamine paradigm but the paradigm is useful even for cases that require muscle relaxation&#46; In 25 years&#44; well over 1000 classical abdominoplasties have been performed with spontaneous ventilation&#44; propofol-ketamine anesthesia without NMBs&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">From the two-lead&#44; processed EEG information on the patient&#39;s forehead&#44; BIS produces a number between 0 and 100&#46; The lower the number&#44; the deeper the <span class="elsevierStyleItalic">hypnotic</span> portion of sedation&#47;anesthesia level &#40;BIS does not measure analgesia&#41;&#46; BIS values between 60 and 75 may be categorized as moderate to deep sedation&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">8</span></a> not general anesthesia&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">9</span></a> Real-time BIS&#47;EMG monitored propofol-ketamine &#40;aka &#8216;Goldilocks&#8217;&#41; anesthesia critically depends on the surgeon&#39;s <span class="elsevierStyleItalic">adequate</span> local analgesia to avoid the need for intra-operative opioids&#46; Absent the common&#44; systemic administration of opioids&#44; Goldilocks anesthesia could properly be called <span class="elsevierStyleItalic">partial</span> intravenous anesthesia &#40;PIVA&#41; but not total or TIVA&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Using the EMG as the secondary trace to BIS provides a <span class="elsevierStyleItalic">real-time</span>&#44; very useful signal that precedes as well as <span class="elsevierStyleItalic">stays ahead</span> of abrupt patient changes in sedation level&#46; There are no spinal reflexes capable of stimulating the forehead <span class="elsevierStyleItalic">frontalis</span> muscle&#46; Patient movement without EMG spike translates to spinal cord &#40;or maybe brain stem but not cortical&#41; originated movement&#44; not awareness or recall&#44; and the need for additional local analgesia&#44; not &#8216;deeper&#8217; anesthesia&#46; Knowledge of the source of the patient movement has led to more precise treatment of the cause&#44; i&#46;e&#46; inadequate local analgesia&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">After an incremental propofol induction &#40;i&#46;e&#46; BIS<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>75 with baseline EMG&#41;&#44; the addition of a 50<span class="elsevierStyleHsp" style=""></span>mg dissociative dose of ketamine does not prevent the use of BIS to titrate propofol&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">10</span></a> An EMG spike signifies incipient arousal and demands prompt additional propofol to return or &#8216;drive&#8217; the EMG spike back to baseline&#46; EMG spikes should be treated <span class="elsevierStyleItalic">as if</span> they were heart rate or blood pressure changes&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">11</span></a> Despite abandoning midazolam premedication&#44; no patient reported awareness or recall for the 20 years of propofol titrated to 60<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>BIS<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>75 with baseline EMG followed by a 50<span class="elsevierStyleHsp" style=""></span>mg dissociative ketamine dose&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">5</span></a> Since 1992&#44; both 50<span class="elsevierStyleHsp" style=""></span>kg females as well as 100<span class="elsevierStyleHsp" style=""></span>kg male patients were observed to remain motionless with the same 50<span class="elsevierStyleHsp" style=""></span>mg ketamine dose&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">5</span></a> Clinically&#44; these 100<span class="elsevierStyleHsp" style=""></span>kg male patients do not appear to have twice the brain size as their smaller&#44; 50<span class="elsevierStyleHsp" style=""></span>kg female counterparts&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">BIS between 40 and 60 is accepted as sedation &#40;or hypnosis&#41; compatible with general anesthesia&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">12&#44;13</span></a> Below 40 is <span class="elsevierStyleItalic">overmedicated</span> and likely responsible for much of the postoperative cognitive dysfunction&#44; delirium&#44; dementia and death<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">14</span></a> that results when a brain monitor is <span class="elsevierStyleItalic">not</span> used during anesthesia&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">15</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Absence of a real-time electromyogram &#40;EMG&#41; spike <span class="elsevierStyleItalic">at the time of skin incision</span> we interpret to mean the midbrain NMDA receptors have been blocked&#46; The pre-emptive 50<span class="elsevierStyleHsp" style=""></span>mg ketamine appears to block noxious&#44; afferent cortical input&#46; Based on the near total lack of postoperative opioid rescue&#44; the patient&#39;s brain does not appear to receive knowledge of the surgeon&#39;s incursion into the body&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">16</span></a> We call this ketamine phenomenon <span class="elsevierStyleItalic">non-opioid</span>&#44; preemptive analgesia &#40;NOPA&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">17&#44;18</span></a> During the case&#44; EMG spikes signal incipient arousal and the need for more propofol until the EMG in sufficient amounts to return the spike to the bottom of the screen&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Usually it takes between 12 and 72<span class="elsevierStyleHsp" style=""></span>h postoperatively for patients to become aware that surgery has happened&#46; In the interval between anesthesia emergence and pain awareness&#44; healing appears to be taking place&#46; The apparent effect of delayed pain perception is patients having less opioid requiring pain with which to deal&#46; While patients do receive opioid prescriptions for postoperative pain&#44; most take much fewer doses than prior to NOPA and almost never ask for a pain prescription refill&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The outcomes of 20 years of <span class="elsevierStyleItalic">brain monitored</span>&#44; propofol ketamine &#40;&#8216;Goldilocks&#8217;&#41; anesthesia for more than 4000 patients&#63; Not a single hospital admission for pain or PONV&#46; The lowest published PONV rate &#40;0&#46;6&#37;&#41; without anti-emetics in an Apfel-defined&#44; high risk patient population was also the outcome of my opioid free anesthesia&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">4</span></a> The Society for Opioid Free Anesthesia &#40;SOFA&#41; is new CRNA anesthesia organization following my 25-year path&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">What do cosmetic surgery and medically indicated surgery have in common&#63; Both cross the skin barrier to get to the surgical field&#46; Once most anesthesiologists and nurse anesthetists wean themselves from routinely giving patients opioids <span class="elsevierStyleItalic">during</span> surgery and adopt my published approach for NOPA&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">19</span></a> we may able to make a big difference in the number of addicts created from routine opioid administration during most surgery&#46;</p></span>"
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos