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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Hb POC<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1.37<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>0.95<span class="elsevierStyleHsp" style=""></span>*<span class="elsevierStyleHsp" style=""></span>Hb.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. López, L. Gómez, G. Petinal, N. Adán, S. Alvarado, N. Carballo" "autores" => array:6 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "López" ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Gómez" ] 2 => array:2 [ "nombre" => "G." "apellidos" => "Petinal" ] 3 => array:2 [ "nombre" => "N." "apellidos" => "Adán" ] 4 => array:2 [ "nombre" => "S." "apellidos" => "Alvarado" ] 5 => array:2 [ "nombre" => "N." "apellidos" => "Carballo" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935618300094" "doi" => "10.1016/j.redar.2018.01.005" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935618300094?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192918300520?idApp=UINPBA00004N" "url" => "/23411929/0000006500000005/v1_201805120427/S2341192918300520/v1_201805120427/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial article</span>" "titulo" => "Opioid free anesthesia with BIS/EMG monitored propofol-ketamine" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "243" "paginaFinal" => "245" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "B.L. Friedberg" "autores" => array:1 [ 0 => array:3 [ "nombre" => "B.L." "apellidos" => "Friedberg" "email" => array:1 [ 0 => "narkose0126@gmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Presidente y fundador, Goldilocks Anesthesia Foundation, Newport Beach, CA, United States" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Anestesia libre de opioides con propofol-ketamina monitorizada mediante BIS/EMG" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In March 1992, work began in a board certified, plastic surgeon's office that, in 1990, had experienced a fentanyl-related death of an otherwise healthy, postpartum woman for breast augmentation surgery. Understandably, that surgeon forbade use of <span class="elsevierStyleItalic">any</span> opioids for anesthesia. In addition, his office did not perform enough cases to justify the cost of an anesthesia machine. After hearing Vinnik's diazepam ketamine technique for cosmetic surgery anesthesia,<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 (i.e. dissociated) for the surgeon's local anesthesia injection <span class="elsevierStyleItalic">after</span> achieving loss of lid reflex and loss of verbal response with incremental propofol doses.<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>, <span class="elsevierStyleItalic">orbicularis oris</span>, <span class="elsevierStyleItalic">masseter</span> & <span class="elsevierStyleItalic">temporalis</span> muscles in addition to spontaneous ventilation. Elective cosmetic surgery patients will complain of a sore throat if their airways have been instrumented. It was a great surprise (and delight) that <span class="elsevierStyleItalic">none</span> of the first 50 patients needed postoperative opioid treatment for pain, experienced PONV, or had hallucinations, dysphorias, flashbacks, hypertension, tachycardia or sore throats.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">3,4</span></a> Hallucination-free ketamine use has remained consistent for the 25 years of this opioid free, office-based cosmetic surgery anesthesia practice for more than 6000 patients.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">5</span></a> In Europe, noted Belgian anesthesiologist, Dr. Jan Mulier and his followers have been using ketamine and other adjuvants for opioid free anesthesia for bariatric and other surgery.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">After June 1997, having found no reduction of propofol dose with either 2 or 4<span class="elsevierStyleHsp" style=""></span>mg midazolam premedication,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">5</span></a> midazolam was omitted from the propofol ketamine paradigm. Glycopyrrolate 0.2<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. 50<span class="elsevierStyleHsp" style=""></span>mcg<span class="elsevierStyleHsp" style=""></span>kg<span class="elsevierStyleSup">−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 <75. See Table 1 The December 1997 addition of the BIS monitor provided a quantitative, <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; i.e. <75 with <span class="elsevierStyleItalic">baseline</span> EMG of the facial <span class="elsevierStyleItalic">frontalis</span> muscle, as real time a signal as is the EKG of the cardiac muscle. EMG signals persist in the presence of Botox or neuromuscular blocking (NMB) agents. NMB use has never been part of the propofol-ketamine paradigm but the paradigm is useful even for cases that require muscle relaxation. In 25 years, well over 1000 classical abdominoplasties have been performed with spontaneous ventilation, propofol-ketamine anesthesia without NMBs.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">From the two-lead, processed EEG information on the patient's forehead, BIS produces a number between 0 and 100. The lower the number, the deeper the <span class="elsevierStyleItalic">hypnotic</span> portion of sedation/anesthesia level (BIS does not measure analgesia). BIS values between 60 and 75 may be categorized as moderate to deep sedation,<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">8</span></a> not general anesthesia.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">9</span></a> Real-time BIS/EMG monitored propofol-ketamine (aka ‘Goldilocks’) anesthesia critically depends on the surgeon's <span class="elsevierStyleItalic">adequate</span> local analgesia to avoid the need for intra-operative opioids. Absent the common, systemic administration of opioids, Goldilocks anesthesia could properly be called <span class="elsevierStyleItalic">partial</span> intravenous anesthesia (PIVA) but not total or TIVA.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Using the EMG as the secondary trace to BIS provides a <span class="elsevierStyleItalic">real-time</span>, very useful signal that precedes as well as <span class="elsevierStyleItalic">stays ahead</span> of abrupt patient changes in sedation level. There are no spinal reflexes capable of stimulating the forehead <span class="elsevierStyleItalic">frontalis</span> muscle. Patient movement without EMG spike translates to spinal cord (or maybe brain stem but not cortical) originated movement, not awareness or recall, and the need for additional local analgesia, not ‘deeper’ anesthesia. Knowledge of the source of the patient movement has led to more precise treatment of the cause, i.e. inadequate local analgesia.</p><p id="par0025" class="elsevierStylePara elsevierViewall">After an incremental propofol induction (i.e. BIS<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>75 with baseline EMG), 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.<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 ‘drive’ the EMG spike back to baseline. EMG spikes should be treated <span class="elsevierStyleItalic">as if</span> they were heart rate or blood pressure changes.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">11</span></a> Despite abandoning midazolam premedication, no patient reported awareness or recall for the 20 years of propofol titrated to 60<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>BIS<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>75 with baseline EMG followed by a 50<span class="elsevierStyleHsp" style=""></span>mg dissociative ketamine dose.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">5</span></a> Since 1992, 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.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">5</span></a> Clinically, these 100<span class="elsevierStyleHsp" style=""></span>kg male patients do not appear to have twice the brain size as their smaller, 50<span class="elsevierStyleHsp" style=""></span>kg female counterparts.</p><p id="par0030" class="elsevierStylePara elsevierViewall">BIS between 40 and 60 is accepted as sedation (or hypnosis) compatible with general anesthesia.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">12,13</span></a> Below 40 is <span class="elsevierStyleItalic">overmedicated</span> and likely responsible for much of the postoperative cognitive dysfunction, delirium, 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.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">15</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Absence of a real-time electromyogram (EMG) spike <span class="elsevierStyleItalic">at the time of skin incision</span> we interpret to mean the midbrain NMDA receptors have been blocked. The pre-emptive 50<span class="elsevierStyleHsp" style=""></span>mg ketamine appears to block noxious, afferent cortical input. Based on the near total lack of postoperative opioid rescue, the patient's brain does not appear to receive knowledge of the surgeon's incursion into the body.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">16</span></a> We call this ketamine phenomenon <span class="elsevierStyleItalic">non-opioid</span>, preemptive analgesia (NOPA).<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">17,18</span></a> During the case, 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.</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. In the interval between anesthesia emergence and pain awareness, healing appears to be taking place. The apparent effect of delayed pain perception is patients having less opioid requiring pain with which to deal. While patients do receive opioid prescriptions for postoperative pain, most take much fewer doses than prior to NOPA and almost never ask for a pain prescription refill.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The outcomes of 20 years of <span class="elsevierStyleItalic">brain monitored</span>, propofol ketamine (‘Goldilocks’) anesthesia for more than 4000 patients? Not a single hospital admission for pain or PONV. The lowest published PONV rate (0.6%) without anti-emetics in an Apfel-defined, high risk patient population was also the outcome of my opioid free anesthesia.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">4</span></a> The Society for Opioid Free Anesthesia (SOFA) is new CRNA anesthesia organization following my 25-year path.</p><p id="par0050" class="elsevierStylePara elsevierViewall">What do cosmetic surgery and medically indicated surgery have in common? Both cross the skin barrier to get to the surgical field. 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,<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.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:2 [ 0 => array:3 [ "etiqueta" => "1" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Baseline EMG is defined either as ‘30’ on the left-side BIS scale or ‘0’ on the right-side EMG scale).</p>" "identificador" => "fn0005" ] 1 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Friedberg BL. Anestesia libre de opioides con propofol-ketamina monitorizada mediante BIS/EMG. Rev Esp Anestesiol Reanim. 2018;65:243–245.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:19 [ 0 => array:3 [ "identificador" => "bib0100" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "An intravenous dissociation technique for outpatient plastic surgery: tranquility in the office surgical facility" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "C.A. 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