If you are interested in or have questions about anesthesia, whether you are a patient, the loved one of a patient, or a medical professional, you will find Dr. Friedberg’s insights interesting and useful.

We welcome your questions and invite you to submit them on the Contact Us Page.

Liposuction Death in Miami/Response

http://www.nbcmiami.com/news/local/Married-Mother-Dies-After-Cosmetic-Surgery-in-Miami-415819243.html

The Florida Medical Board marches to the tune of the American Society of Plastic Surgeons (ASPS). This death at the hands of a plastic, not cosmetic, surgeon will be ‘whitewashed’ just like the death of 17-year old, otherwise healthy, Stephanie Kuleba was in 2008 (http://www.nbcnews.com/id/23808301/ns/health-childrens_health/t/teen-dies-after-corrective-breast-surgery/) in a Boca Raton plastic surgeon’s office. Dermatologic cosmetic surgeons performing liposuction in Florida have historically been subject to much greater scrutiny and discipline than their plastic surgery counterparts.

If there was no fat (or blood clot) embolus found in this woman’s lungs at autopsy, one must look to anesthesia for the likely reason for a patient to stop breathing after surgery. Residual opioids and muscle relaxants are likely the guilty culprits for this type of lethal outcome. These agents are far too casually demanded by plastic surgeons who prefer general anesthesia over IV sedation or even more simply dilute local anesthesia (Klein’s solution) for liposuction.

Florida cosmetic surgeons, like dermatologists, more often use dilute local anesthesia and according to a Coldiron study in Florida & Alabama on liposuction deaths (https://www.ncbi.nlm.nih.gov/pubmed/22093178), plastic surgeons had more fatalities than dermatologic surgeons performing liposuction.

As a California based, board certified anesthesiologist involved with office based liposuction cases over the past 25 years and a recognized authority on IV sedation for cosmetic surgery, I am very saddened by yet another avoidable death for a patient without a medical reason to have surgery. Only patients with a medical reason for surgery should be exposed to the risks of general anesthesia. Yet for incomprehensible reasons, my plastic surgeon colleagues continue to dogmatically demand general anesthesia for elective cosmetic surgery patients.

Download a free, no obligation copy of ‘Getting Over Going Under, 5 things you MUST know before anesthesia’ @ goldilocksfoundation.org. No request for email or donations are asked when pushing the download button.


Thunder from Down Under

Dear Dr Friedberg

Well, it was an interesting journey! I saw the surgeon today which is two weeks after my surgery. He says it’s healing well and the final result will be good. He also replied to my question that I was a good patient in the operating theater.

It did not start well a month ago. The anesthetist told me the operation would be under general anesthetic using gas. A BIS might be used with a target of 40 to 50, although many people thought the monitor is of little value. He was negative about ketamine. Although I was polite and mainly asked questions, at one point he said rather forcibly that I was trying to tell him how to do his job. Bit surly with no bedside manner. Not good!

To my surprise, he called me two days later. Said he had discussed what I asked for with colleagues and the surgeon, and was willing to use sedation with BIS, propofol and ketamine but there was a chance I might wake up during the procedure. He expressed interest in your 1999 ketamine–BIS–propofol paper, which I had mentioned, so I sent him a copy. When I next spoke with him the week before surgery he said he had read the paper and would try to follow it as closely as possible. The surgeon would use local anesthetic.

I don’t recall going under slowly – it just happened – but I woke up feeling fine. Surgery about 1-1/2 hours woke up inside 2 hours. Back home, did the newspaper crossword as usual that afternoon and ate normally. My wife has noticed no anesthesia after effects and my routine quickly returned to normal. Prior to the event, the nurse at the surgeon’s office said that I would be ‘pretty beat up in the week after surgery’ due to the anesthetic. This was not the case which I put down to use of sedation/ketamine instead of general anesthetic normally used here.

The anesthetist is with Australia’s leading anesthetic practice. I think this would have been a first, in Perth at any rate. It’s worked out well.

I am grateful and thank you for the information you sent, for the support you provided to me (a complete stranger), and for your interest in my case.

May I wish you a Merry Christmas (as we say here in Australia) and best wishes for the year ahead.

Regards

Bob S.

Perth, Australia


Measuring brain waves may help predict a patient’s response to anesthesia

Patterns of alpha oscillations are weaker in people who succumb easily to the drug propofol, study shows.


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Signals in the brain can hint at whether a person undergoing anesthesia will slip under easily or fight the drug, a new study suggests. The results, published January 14 in PLOS Computational Biology, bring scientists closer to being able to tailor doses of the powerful drugs for specific patients.

Drug doses are often given with a one-size-fits-all attitude, says bioengineer and neuroscientist Patrick Purdon of Massachusetts General Hospital and Harvard Medical School. But the new study finds clear differences in people’s brain responses to similar doses of an anesthetic drug, Purdon says. “To me, that’s the key and interesting point.”

Cognitive neuroscientist Tristan Bekinschtein of the University of Cambridge and colleagues recruited 20 people to receive low doses of the general anesthetic propofol. The low dose wasn’t designed to knock people out, but to instead dial down their consciousness until they teetered on the edge of awareness — a point between being awake and alert and being drowsy and nonresponsive.

While the drug was being delivered, participants repeatedly heard either a buzzing sound or a noise and were asked each time which they heard, an annoying question designed to gauge awareness. Of the 20 people, seven were sidelined by the propofol and they began to respond less. Thirteen other participants, however, kept right on responding, “fighting the drug,” Bekinschtein says.

EEG measurements that tracked electrical activity in the brain revealed a brain signature that differed between these two groups. In people who resisted the propofol, a particular type of brain wave called an alpha oscillation appeared to be strong and efficient, with lots of connections between near and far brain areas, the team found. In contrast, people who succumbed easily to the drug had weaker, less efficient alpha wave behavior.

This difference was present even before the drug was delivered, Bekinschtein says. At the beginning of the experiment, people already showed predictive alpha wave signatures. The results raise the prospect that a presurgical EEG measurement could pinpoint the lowest dose of drug that would still put a person under while reducing potential side effects.

“It’s adding a layer of complexity,” Bekinschtein says. “But the beauty of this is that it’s a layer of complexity that we can measure before giving the drug.”

EEG machines are widely available in clinical settings, and Bekinschtein and colleagues are trying to adapt their results to be useful to anesthesiologists. “It’s a very simple analysis to do” once the mathematical framework is in place, Bekinschtein says. He and others hope to design a way for physicians to enter a person’s raw EEG data and get an estimate of anesthesia susceptibility.

Purdon cautions that the results are based on a limited number of people. “It’s a preliminary finding in that regard,” he says. And more work is needed to translate the results so that they can be applied to individual patients. Nonetheless, he says, the results “all really make sense.”


Citiations

S. Chennu et al. Brain connectivity dissociates responsiveness from drug exposure during propofol-induced transitions of consciousness. PLOS Computational Biology. Published online January 14, 2016. doi: 10.1371/journal.pcbi.1004669.


Further Reading

L. Sanders. Age affects brain’s response to anesthesia. Science News Online, July 28, 2015.


Dear ‘Sleepy’ from Buffalo,

Thank you for your help for my recent operation.

Here is a copy of the email to enlighten you as to why I was so particular about the anesthesia to be used.

Start at the very bottom of this document to see my original email to Dr. Friedberg. His reply explains why I only wanted to use propofol.

Take a peek at his book, ‘Getting Over Going Under’ (free from his new website www.goldilocksfoundation.org) It explains a lot about what a patient needs to know about anesthesia, especially if they are over 50 and going to have an operation that requires sedation during an operation.

The book will also explain why anesthesiologists don’t take the simple route for smaller operations like cataracts or cosmetic surgery. But, they should be using a BIS Brain Monitor for larger operations and most patients would not know to even ask about this. This meter can avoid the problems associated with being over-medicated with anesthesia.

By requesting “NO BENZOS” I had NO PAIN, NO NAUSEA, NO HEADACHES, NO FATIGUE, NO PROBLEMS. Propofol was used and just put me to sleep. When I awoke, I was in the recovery area and was wide awake and alert. We went for breakfast and then I went to work. I was PAIN-FREE, not tired, not drowsy,  not sleepy, not dizzy; BUT, I had to demand it, otherwise, the anesthesiologist would have given me the usual cocktail of benzo-type ( benzodiazepines) drugs.

Feel free to forward this information to anyone you know that may be getting ready for surgery.

Have a nice Thanksgiving.

Dan


 

My response:

First, let me sympathize with your wife’s condition & extend my fervent wish that I could offer something to reverse it. Sadly, I cannot.
Second, your cataract surgery is so short that it would not be of any benefit to have the BIS brain monitor.

PUBLIC EDUCATION MESSAGE: NO MAJOR SURGERY UNDER ANESTHESIA WITHOUT A BRAIN MONITOR

Your cataract surgery, while major in your eyes, is not ‘major’ surgery.

Next, the only thing I would tell your anesthesiologist is ‘no benzodiazepines please.’ Just a little propofol for sedation would be great.

Lastly, after MUCH frustration with my colleagues’ reticence to adopt this monitor, I created this following in a fit of despair…& created this…
Here is my book you requested… I wrote it in plain English for the general public to help deal with anesthesia fears…
virus free

I need your assistance.

The best thing you can do with my book after reading it is sharing it with as many of your friends & family members, especially those over 50, as you can.
I cannot access those people myself & they might not perceive such a contact from me as welcome.
The reason for my non-profit foundation (& disclaimer) is to avoid any suspicion that I am somehow making money by my advocacy.



 

Dan’s original email

Dear Dr. Friedberg,

My wife had 3 lumpectomies and a mastectomy within 4 months. (About 5 years prior to these operations, she had a heart valve replaced.) She has developed dementia/ Alzheimer’s since the mastectomy.

I am about to have cataract surgery and would like to obtain a copy of your book:  ‘Getting Over Going Under, 5 things you MUST know before anesthesia.’ Will your advice apply to the anesthesiologist for cataract surgery?

I had cataract surgery on my other eye about 2 years ago. When I began to question the anesthesiologist, he was very put out and abrupt with any answers. His attitude was about doing his job for 20+ years and he knew what he was doing. I want to be ahead of the curve this time around—scheduled for 11/19.

If I am told they don’t have a brain monitor at the surgery center (not in a hospital), is this something that can be readily obtained, borrowed or purchased? And, if they don’t have the equipment, is it likely that the doctor would be trained in how to use it?

Thank you in advance for any guidance.

 


Propofol… Less Confusion after Surgery

heart surgeryQ. After reading your column on the aftereffects of anesthesia, I want to share my own experience.

I had severe memory lapses for months after undergoing anesthesia. It was like knowing something was in a filing cabinet, but not being able to see what is in the folder. It is frustrating to know the information is there, but you can’t access it.

Thankfully, my brain function did return to normal, but it took months. My physician suggested propofol for future surgeries. I have needed anesthesia a few more times over the last several years and have not experienced aftereffects again.

A. Post-operative cognitive decline is surprisingly common, though the cause remains controversial. Propofol is an injectable anesthetic. One study showed less impairment among patients getting propofol compared to those getting the inhaled anesthetic sevoflurane (Clinical Interventions in Aging, online Sept. 24, 2014).

It makes sense to ask the surgeon ahead of time if a peripheral nerve block would be appropriate. In some cases, such as knee surgery, that may be another option (Clinical Interventions in Aging, online Feb. 18, 2014).

People who find that they are spacey or forgetful after surgery should be patient with themselves. In most cases, the cognitive problems (which may also be linked to insomnia) will disappear over time.

 

  1. Barry
    Corona del Mar, CA

Anesthesia providers can only guess how much anesthetic you might need. Without a brain monitor, one American patient dies every day from anesthesia over medication. Prior to 1996, to insure an adequate experience, we tend to err on the side of too much. Since the FDA approval of the BIS brain monitor, it is now not only possible but also highly desirable to directly measure individual response to avoid brain fog (aka postoperative cognitive dysfunction or POCD). Watch You Tube ‘Going under with Goldilocks anesthesia.’ Learn what you need to know by reading ‘Getting Over Going Under.’ Complimentary copies from www.goldilocksfoundation.org. DISCLAIMER: Neither I, nor my non-profit Goldilocks Anesthesia Foundation, receive financial support from makers of the BIS monitor.


Goldilocks anesthesia postoperative delirium concerns validated again by brain monitor maker, Covidien

Evidence and Supporting Resources

Delirium: Prevalence

Ten percent of patients over 50 will experience some level of delirium postoperatively, and the incidence increases up to 60% for those over 65. In young adults, the occurrence of emergence delirium in the PACU ranges from 3 to 20%.1

In an article published in the International Journal of Geriatric Psychiatry, the authors conclude: “In long-term care, prevalence ranges between 1.4% and 70%, depending on diagnostic criteria and on the prevalence of dementia. Most studies agree that older people who previously experienced delirium have a higher risk of dementia and a higher mortality rate. Population and long-term care studies show the same tendency.”2

Delirium: Risks to Healthcare Providers

In an era of increasing accountability and a focus on outcomes-based medicine, the risk to HCPs is high.According to Dr. Sharon K. lnnoye, a professor of medicine at Harvard Medical School and director of the Aging Brain Center at Hebrew Seniorlife in Boston, “Not only do patients have a 25-70% higher chance of dying during their hospital stay, but they are also at a 62% higher risk of mortality in the following year.”3

The American Geriatrics Society now believes there is sufficient peer-reviewed published data on levels of anesthesia as an independent predictor of delirium in the postsurgical setting. Their Expert Panel on Postoperative Delirium in Older Adults consensus statement on intraoperative monitoring asserts that practitioners may use “processed electroencephalographic monitors of anesthetic depth during intravenous sedation or general anesthesia of older patients to reduce postoperative delirium.”4

Delirium: Costs to Hospitals

Numerous studies have shown an increased risk of institutionalization, dementia and death in patients with postoperative delirium5 as well as increases in hospital length of stay by up to six days.6 Moreover, “total cost estimates attributable to delirium ranged from $16,303 to $64,421 per patient”.5

According to a study in The Journal of American Geriatric Society, post-hospital treatment for delirium costs $143-$152 billion per year,5 which includes additional rehabilitation services, home health care and nursing home care.7

Delirium: How BIS™ monitoring can help mitigate risk

Postoperative delirium is preventable in up to 40% of such cases,6 with a proper screening program, the identification of risk factors and the implementation of evidence-based monitoring methods within the OR.

Brain function monitoring-guided anesthesia dosing may decrease the rate of postoperative delirium.6,7,11,12 Monitoring with Bispectral Index™ (BIS™’) technology during surgical procedures gives anesthesia providers the ability to directly monitor the anesthetic effect on the patient’s brain to optimize the anesthetic dosing for the individual.

Peer-reviewed literature has shown BIS-guided anesthetic titration may aid in a reduction in the incidence of delirium in elderly and other patient populations at increased risk.5

BIS monitoring has also been clinically shown to reduce primary anesthetic delivery (as much as 50%) and promote faster wake-up, recovery and discharge from the PACU.11,12,13,14 BIS also reduces the risk of awareness or ”wake-up” during surgery by up to 80%.14

BIS™ monitoring ensures a more positive experience for patients

Brain function monitoring with Bispectral lndexn. (BIS™) technology during surgical procedures gives anesthesiologists the ability to directly monitor the anesthetic effect on the patient’s brain to optimize dosing,which can result in:

  • Improved safety: Helps the anesthesia professional optimize the anesthetic dosing for each patient
  • Reduced postoperative delirium: Research has now shown that monitoring brain function monitoring-guided anesthesia dosing may decrease the rate of postoperative delirium11,12
  • Reduced costs: Reduction in primary anesthetic delivery of up to 50%; fewer delirium episodes may reduce treatment costs6,13
  • Improved patient satisfaction: Faster wake-up, recovery and discharge from PACU; 80% less risk of patient awareness during surgery14,15,16

View the statistics: Incidence of post-operative delirium

References
  1. Lepouse, C., Lautner, C., et al. Emergence delirium in adults in postanaesthesia care unitBritish Journal Anaesthesia. May 2, 2006;(96) 747-53
  2. de Lange, E., Verhaak, P.F., van der Meer, K. Prevalence, presentation and prognosis of delirium in older people in the population, at home and in long term care: a reviewInt J Geriatr Psychiatry. Feb 28, 2013.
  3. Selinger, S. Preventing Hospital Delirium. The New Old Age blog. New York Times Website. November 11,2011. Accessed March 6, 2015.
  4. Inouye, Sharon K. et al. Postoperative Delirium in Older Adults: Best Practice Statement from the American Geriatrics Society. lntraoperative Measures to Prevent DeliriumJ Am Coll Surg. 2014;220;2 ,136-148.e1.
  5. Leslie, D.L., Marcantonio, E.R., Zhang, Y., Leo-Summers, L., & Inouye, S.K. (2008). One-year health care costs associated with delirium in the elderly populationArchives of Internal Medicine. 168(1), 27-32.
  6. Whitlock, E.L., Torres, B.A., Lin, N., Helsten, D.L., Nadelson, M.R., & Mashour, G.A. (2014). Postoperative delirium in a substudy of cardiothorac ic surgical patients in the BAG-RECALL clinical trialAnesthesia & Analegesia. 118(4),809-817.
  7. Sieber, F.E., Zakriya, K.J., Gottschalk, A., Blute, M.R., Lee, H.B., Rosenberg, P.B., Mears S.C. Sedation depth during spinal anesthesia and the development of postoperative delirium in elderly patients undergoing hip fracture repairMayo Clin Proc. 2010 Jan;85(1):18-26.
  8. Inouye, S.K., Bogardus, S.T. Jr., Charpentier, P.A. et al. A multicomponent intervention to prevent delirium in hospitalized older patientsN Engl J Med. 1999;340:669-676. (ET)
  9. Marcantonio, E.R., Flacker, J.M., Wright, R.J. et al. Reducing delirium after hip fracture: A randomized trialJ Am Geriatr Soc. 2001;49:516-522.(ET)
  10. Rubin, F.H., Neal, K., Fenlon, K., Hassan, S., Inouye, S.K. Sustainability and scalability of the hospital elder life program at a community hospitalJ Am Geriatr Soc. Feb 2011;59(2):359-65.
  11. Chan, M.T., Cheng, B.C., Lee, T.M. et al. BIS-guided anesthesia decreases postoperative delirium and cognitive declineJ Neurosurg Anesthesiol. 2013; 25: 33-42
  12. Radtke, F. M., Franck, M., Lendner, J., Kruger, S., Wernecke, K. D., & Spies, C. D. (2013). Monitoring depth of anaesthesia in a randomized trial decreases the rate of postoperative delirium but not postoperative cognitive dysfunctionBr J Anaesth. 2013; 110: i98-105.
  13. Kaplan, L.J., Bailey, H. Bispectral index (BIS) monitoring of ICU patients on continuous infusion of sedatives and paralytics reduces sedative drug utilization and costCrit Care Med. 2000;4(Suppl):S110.
  14. Gan, T.J., Glass, P. S., Windsor, A., Payne, F., Rosow, C., Sebel, P., & Manberg, P. (1997). Bispectral index monitoring allows faster emergence and improved recovery from propofol, alfentanil, and nitrous oxide anesthesiaAnesthesiology. 87(4), 808-815.
  15. Myles P.S., Leslie, K., McNeil, J., Forbes, A., Chan, M.T. Bispectral index monitoring to prevent awareness during anaesthesia: the B-Aware randomised controlled trialLancet. 2004;363(9423):1757-1763.
  16. White, P.F., Ma, H., Tang, J., Wender, R.H., Sloninsky, A., Kariger, R. Does the use of electroencephalographic bispectral index or auditory evoked potential index monitoring facilitate recovery after desflurane anesthesia in the ambulatory setting?Anesthesiology. 2004; 100(4):811-817.