Opioid free anesthesia with BIS/EMG monitored propofol-ketamine

Friedberg, B.L.
doi:10.1016/j.redare.2017.11.016
 array:23 [
  "pii" => "S2341192918300015"
  "issn" => "23411929"
  "doi" => "10.1016/j.redare.2017.11.016"
  "estado" => "S300"
  "fechaPublicacion" => "2018-05-01"
  "aid" => "886"
  "copyright" => "Sociedad Espa&#241;ola de Anestesiolog&#237;a&#44; Reanimaci&#243;n y Terap&#233;utica del Dolor"
  "copyrightAnyo" => "2018"
  "documento" => "article"
  "crossmark" => 1
  "subdocumento" => "sco"
  "cita" => "Revista Espa&#241;ola de Anestesiolog&#237;a y Reanimaci&#243;n &#40;English Version&#41;. 2018;65:243-5"
  "abierto" => array:3 [
    "ES" => false
    "ES2" => false
    "LATM" => false
  ]
  "gratuito" => false
  "lecturas" => array:2 [
    "total" => 8
    "formatos" => array:2 [
      "HTML" => 7
      "PDF" => 1
    ]
  ]
  "Traduccion" => array:1 [
    "es" => array:19 [
      "pii" => "S0034935617302700"
      "issn" => "00349356"
      "doi" => "10.1016/j.redar.2017.11.011"
      "estado" => "S300"
      "fechaPublicacion" => "2018-05-01"
      "aid" => "886"
      "copyright" => "Sociedad Espa&#241;ola de Anestesiolog&#237;a&#44; Reanimaci&#243;n y Terap&#233;utica del Dolor"
      "documento" => "article"
      "crossmark" => 1
      "subdocumento" => "sco"
      "cita" => "Rev Esp Anestesiol Reanim. 2018;65:243-5"
      "abierto" => array:3 [
        "ES" => false
        "ES2" => false
        "LATM" => false
      ]
      "gratuito" => false
      "lecturas" => array:2 [
        "total" => 786
        "formatos" => array:3 [
          "EPUB" => 2
          "HTML" => 682
          "PDF" => 102
        ]
      ]
      "es" => array:10 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">EDITORIAL</span>"
        "titulo" => "Anestesia libre de opioides con propofol-ketamina monitorizada mediante BIS&#47;EMG"
        "tienePdf" => "es"
        "tieneTextoCompleto" => "es"
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "243"
            "paginaFinal" => "245"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "en" => array:1 [
            "titulo" => "Opioid free anesthesia with BIS&#47;EMG monitored propofol-ketamine"
          ]
        ]
        "contieneTextoCompleto" => array:1 [
          "es" => true
        ]
        "contienePdf" => array:1 [
          "es" => true
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "B&#46;L&#46; Friedberg"
            "autores" => array:1 [
              0 => array:2 [
                "nombre" => "B&#46;L&#46;"
                "apellidos" => "Friedberg"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "es"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S2341192918300015"
          "doi" => "10.1016/j.redare.2017.11.016"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => false
            "ES2" => false
            "LATM" => false
          ]
          "gratuito" => false
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192918300015?idApp=UINPBA00004N"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935617302700?idApp=UINPBA00004N"
      "url" => "/00349356/0000006500000005/v1_201805080427/S0034935617302700/v1_201805080427/es/main.assets"
    ]
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S2341192918300520"
    "issn" => "23411929"
    "doi" => "10.1016/j.redare.2018.04.005"
    "estado" => "S300"
    "fechaPublicacion" => "2018-05-01"
    "aid" => "905"
    "copyright" => "Sociedad Espa&#241;ola de Anestesiolog&#237;a&#44; Reanimaci&#243;n y Terap&#233;utica del Dolor"
    "documento" => "article"
    "crossmark" => 1
    "subdocumento" => "fla"
    "cita" => "Revista Espa&#241;ola de Anestesiolog&#237;a y Reanimaci&#243;n &#40;English Version&#41;. 2018;65:246-51"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:1 [
      "total" => 0
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>"
      "titulo" => "Is a blood sample for hemoglobins in the transfusional range reliable&#63;"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "246"
          "paginaFinal" => "251"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "&#191;Es fiable una muestra de gasometr&#237;a para hemoglobinas en rango transfusional&#63;"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0005"
          "etiqueta" => "Figure 1"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr1.jpeg"
              "Alto" => 1373
              "Ancho" => 1418
              "Tamanyo" => 130505
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Pearson linear regression between POC and central laboratory haemoglobin levels with 95&#37; confidence interval for the mean and 95&#37; individual confidence interval&#46; Hb POC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;37<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>0&#46;95<span class="elsevierStyleHsp" style=""></span>&#42;<span class="elsevierStyleHsp" style=""></span>Hb&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "A&#46; L&#243;pez, L&#46; G&#243;mez, G&#46; Petinal, N&#46; Ad&#225;n, S&#46; Alvarado, N&#46; Carballo"
          "autores" => array:6 [
            0 => array:2 [
              "nombre" => "A&#46;"
              "apellidos" => "L&#243;pez"
            ]
            1 => array:2 [
              "nombre" => "L&#46;"
              "apellidos" => "G&#243;mez"
            ]
            2 => array:2 [
              "nombre" => "G&#46;"
              "apellidos" => "Petinal"
            ]
            3 => array:2 [
              "nombre" => "N&#46;"
              "apellidos" => "Ad&#225;n"
            ]
            4 => array:2 [
              "nombre" => "S&#46;"
              "apellidos" => "Alvarado"
            ]
            5 => array:2 [
              "nombre" => "N&#46;"
              "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&#47;EMG monitored propofol-ketamine"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "243"
        "paginaFinal" => "245"
      ]
    ]
    "autores" => array:1 [
      0 => array:3 [
        "autoresLista" => "B&#46;L&#46; Friedberg"
        "autores" => array:1 [
          0 => array:3 [
            "nombre" => "B&#46;L&#46;"
            "apellidos" => "Friedberg"
            "email" => array:1 [
              0 => "narkose0126&#64;gmail&#46;com"
            ]
          ]
        ]
        "afiliaciones" => array:1 [
          0 => array:2 [
            "entidad" => "Presidente y fundador&#44; Goldilocks Anesthesia Foundation&#44; Newport Beach&#44; CA&#44; United States"
            "identificador" => "aff0005"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Anestesia libre de opioides con propofol-ketamina monitorizada mediante BIS&#47;EMG"
      ]
    ]
    "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>"
    "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 &#8216;30&#8217; on the left-side BIS scale or &#8216;0&#8217; on the right-side EMG scale&#41;&#46;</p>"
        "identificador" => "fn0005"
      ]
      1 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Friedberg BL&#46; Anestesia libre de opioides con propofol-ketamina monitorizada mediante BIS&#47;EMG&#46; Rev Esp Anestesiol Reanim&#46; 2018&#59;65&#58;243&#8211;245&#46;</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&#58; tranquility in the office surgical facility"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "C&#46;A&#46; Vinnik"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Plast Reconstr Surg"
                        "fecha" => "1981"
                        "volumen" => "67"
                        "paginaInicial" => "799"
                        "paginaFinal" => "805"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7243983"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Propofol-ketamine technique"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "B&#46;L&#46; Friedberg"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Aesth Plast Surg"
                        "fecha" => "1993"
                        "volumen" => "17"
                        "paginaInicial" => "297"
                        "paginaFinal" => "300"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Hypnotic doses of propofol block ketamine induced hallucinations"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "B&#46;L&#46; Friedberg"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Plast Reconstr Surg"
                        "fecha" => "1993"
                        "volumen" => "91"
                        "paginaInicial" => "196"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8416533"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Propofol-ketamine technique&#44; dissociative anesthesia for office surgery&#58; a five-year review of 1&#44;264 cases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "B&#46;L&#46; Friedberg"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Aesth Plast Surg"
                        "fecha" => "1999"
                        "volumen" => "23"
                        "paginaInicial" => "70"
                        "paginaFinal" => "74"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Can Friedberg&#39;s triad solve persistent anesthesia problems&#63; Over-medication&#44; pain management&#44; postoperative nausea and vomiting"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "B&#46;L&#46; Friedberg"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Plast Reconstr Surg Global Open"
                        "fecha" => "2017"
                        "volumen" => "5"
                        "paginaInicial" => "e1727"
                        "paginaFinal" => "e1734"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Opioid free general anesthesia&#46; A paradigam shift&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "J&#46; Mulier"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Rev Esp Anestesio Reanim"
                        "fecha" => "2017"
                        "volumen" => "64"
                        "paginaInicial" => "427"
                        "paginaFinal" => "430"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Propofol blood concentration and the bispectral index predict suppression of learning during propofol&#47;epidural anesthesia in volunteers"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "K&#46; Leslie"
                            1 => "D&#46;I&#46; Sessler"
                            2 => "M&#46; Schroeder"
                            3 => "K&#46; Walters"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Anesth Analg"
                        "fecha" => "1995"
                        "volumen" => "81"
                        "paginaInicial" => "1269"
                        "paginaFinal" => "1274"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7486115"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Propofol ketamine with bispectral &#40;BIS&#41; index monitoring"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "B&#46;L&#46; Friedberg"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "LibroEditado" => array:4 [
                        "titulo" => "Anesthesia in cosmetic surgery"
                        "paginaInicial" => "1"
                        "paginaFinal" => "13"
                        "serieFecha" => "2007"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "What is general anesthesia&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "B&#46;L&#46; Friedberg"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/PRS.0b013e3181d51741"
                      "Revista" => array:6 [
                        "tituloSerie" => "Plast Reconstr Surg"
                        "fecha" => "2010"
                        "volumen" => "125"
                        "paginaInicial" => "221e"
                        "paginaFinal" => "222e"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20440149"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The effect of dissociative dose of ketamine on the bispectral index &#40;BIS&#41; during propofol hypnosis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "B&#46;L&#46; Friedberg"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Clin Anes"
                        "fecha" => "1999"
                        "volumen" => "11"
                        "paginaInicial" => "4"
                        "paginaFinal" => "7"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "titulo" => "Practice advisory for intraoperative awareness and brain function monitoring"
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Anesthesiology"
                        "fecha" => "2006"
                        "volumen" => "104"
                        "paginaInicial" => "847"
                        "paginaFinal" => "864"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16571982"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Level of consciousness monitoring"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "S&#46; Kelly"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "LibroEditado" => array:4 [
                        "titulo" => "Anesthesia in cosmetic surgery"
                        "paginaInicial" => "23"
                        "paginaFinal" => "28"
                        "serieFecha" => "2007"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The relationship between the bispectral index &#40;BIS&#41; and the Observer Alertness of Sedation Scale &#40;OASS&#41; scores during propofol sedation with and without ketamine&#58; a randomized&#44; double blinded&#44; placebo controlled clinical trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "G&#46; DeOlivera"
                            1 => "M&#46;C&#46; Kendall"
                            2 => "R&#46;J&#46;L&#46; Marcus"
                            3 => "R&#46;J&#46; McCarthy"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s10877-015-9745-0"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Clin Monit Comput"
                        "fecha" => "2016"
                        "volumen" => "30"
                        "paginaInicial" => "495"
                        "paginaFinal" => "501"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26219614"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epidemiology of anesthesia-related Mortality in the United States&#44; 1999&#8211;2005"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "G&#46; Li"
                            1 => "M&#46; Warner"
                            2 => "B&#46;H&#46; Lang"
                            3 => "L&#46; Huang"
                            4 => "L&#46;S&#46; Sun"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Anesthesiology"
                        "fecha" => "2009"
                        "volumen" => "110"
                        "paginaInicial" => "759"
                        "paginaFinal" => "765"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19322941"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0170"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The tree&#44; the forest and standard of care"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "B&#46;L&#46; Friedberg"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/bja/aev211"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Anaesth"
                        "fecha" => "2015"
                        "volumen" => "115"
                        "paginaInicial" => "i114"
                        "paginaFinal" => "i121"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26174296"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "One simple trick to preempt post-op pain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "B&#46;L&#46; Friedberg"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Outpatient Surgery Magazine Paoli&#44; PA&#44; Herrin Publishing Partners LP"
                        "fecha" => "2017"
                        "volumen" => "3"
                        "paginaInicial" => "16"
                        "paginaFinal" => "17"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0180"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Propofol ketamine anesthesia for cosmetic surgery in the office suite"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "B&#46;L&#46; Friedberg"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "LibroEditado" => array:6 [
                        "editores" => "I&#46;Osborne"
                        "paginaInicial" => "39"
                        "paginaFinal" => "50"
                        "serieVolumen" => "vol&#46; 41"
                        "serieTitulo" => "Anesthesia for outside the operating room&#46; Int Anesthesiol Clin"
                        "serieFecha" => "2003"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0185"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Propofol in office-based surgery"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "B&#46;L&#46; Friedberg"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1055/s-2007-979214"
                      "Revista" => array:6 [
                        "tituloSerie" => "Semin Plast Surg"
                        "fecha" => "2007"
                        "volumen" => "21"
                        "paginaInicial" => "129"
                        "paginaFinal" => "132"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20567647"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0190"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Non-opioid analgesia improves outcomes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "B&#46;L&#46; Friedberg"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Anesthesiology"
                        "fecha" => "2000"
                        "volumen" => "93"
                        "paginaInicial" => "582"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10910515"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/23411929/0000006500000005/v1_201805120427/S2341192918300015/v1_201805120427/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "62207"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Editorial article"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/23411929/0000006500000005/v1_201805120427/S2341192918300015/v1_201805120427/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192918300015?idApp=UINPBA00004N"
]
Indexed in:

Follow us:

Subscribe:

Article

Indexed in:

Follow us:

Subscribe:

Article

Subscribe to our newsletter
