No surgery under anesthesia without a brain monitor
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When anesthesia is given without a brain monitor (i.e. the 20th century model of anesthesia care), over-medication is always given for fear of under medication or anesthesia awareness.
The customary monitors (EKG, pulse oximeter, & blood pressure) do a fine job of measuring your brain STEM function. However, thinking, hearing, feeling and remembering are CORTICAL functions.
Brain stem measurements are notoriously unreliable measures of your cortical function. Poor or sub-optimal cortical function is revealed in brain fog or POCD.
FYI, the only post-anesthesia brain function test you will get is ‘able to move all 4 extremities on command,’ an abysmally low level of cortical function.
Only a brain monitor like the BIS measures your cortical function.
The public education message of my non-profit Goldilocks Anesthesia Foundation is simple & direct:
“No surgery under anesthesia without a brain monitor.”
That message is contained within the first line of Friedberg’s Triad
“Measure the brain”
If one follows the second part,
“Preempt the pain”
or 50 mg ketamine 3-5 minutes pre-incision (aka ‘the nifty fifty’),
the need for postop narcotics (opioids) is essentially eliminated
“Emetic drugs abstain”
means no need to give anti-nausea medication to treat narcotic associated postoperative nausea and vomiting (PONV).
Anesthesia awareness is the least important function of a brain monitor.
The avoidance of the nefarious practice of routine over-medication is clearly the greatest benefit of routine brain monitoring (i.e. the 21st century model of anesthesia care).
FWIW, anesthesia fog or POCD lasting more than a year is called anesthesia dementia that, unfortunately, does not go away.
I hope all those affected with POCD resolve in less than a year.
BIS brain monitors can be found in 75% of US hospitals but only used 25% of the time simply because patients do not know to DEMAND them for surgery under anesthesia.
While there may well be many factors involved in POCD, why let anyone play Russian roulette with your brain if you must have surgery?
Before Paul White was retained, as a recognized propofol expert, I was asked, by Murray’s attorney, Michael Flanagan, to defend Conrad Murray’s care of Michael Jackson.
In Flanagan’s attempt to impress me, I was told Murray was such a ‘great’ doctor he didn’t start an IV when performing cardioversion. Flanagan represented that Murray simply put the propofol directly into the patient’s vein.
Upon hearing this description of Murray’s usual practice, my jaw dropped open & my eyes grew large with astonishment & disbelief.
I told Mr. Flanagan that he DID impress me but NOT in the manner in which he was intending. I added there was not any language to adequately describe the degree of recklessness that such an act would involve.
Although Murray had hospital privileges to perform cardiac catheterization with propopfol sedation with audible pulse oximetry monitoring, it is clear from his above described conduct, in addition to the ‘care’ of Michael Jackson, that Murray does not believe the usual safety precautions apply to him. It is not a lack of knowledge that led Murray to conduct himself in such a regular, reckless manner but the fact he is a sociopath.
Murray is a disgrace to the medial profession and never deserves to again hold a license to practice.
What does Obamacare share in common with Milo Minderbinder’s (an officer in “Catch-22”) corporation, wherein everyone has a (worthless) “share?”
Yes, health care is now available to millions more than before, but just try getting it. Or as one cartoon put it succinctly, “Yes, comrade, health care is free in our country, but if you want me to operate with my glasses on, it will be $5,000.”
Barry L. Friedberg
Kudos to Mathews, et al. (1) for more widely disseminating the increased utility of the BIS monitor with trending EMG as a secondary trace. This information has been previously published. (2,3).
Barry L. Friedberg, M.D.
President, Goldilocks Anesthesia Foundation
1. Mathews DM, Clark L, Johansen J, et al. Increases in Electroencephalogram and Electromyogram Variability Are Associated with Increased Incidence of Intraoperative Somatic Response. Anes Analg 2012;114:759-770.
2. Friedberg BL: The effect of a dissociative dose of ketamine on the bispectral (BIS) index during propofol hypnosis. J Clin Anes 1999;11:4-7.
3. Friedberg BL: Propofol ketamine with bispectral (BIS) index monitoring chapter in Friedberg BL, ed.: Anesthesia in Cosmetic Surgery. Cambridge University Press, New York 1-13, 2007.
Today marks the 20th anniversary of my first propofol ketamine anesthetic.
Not many of our colleagues can claim to have created a new paradigm.
One day, I hope most will see the utility of the nifty 50 for any surgery that breaches the skin.
Patients will be delighted, PACU will notice & facility cost efficiency will increase.
Until that day, I shall be thrilled with my accomplishment.
Dr. Friedberg blog post in NY Times
Paul Krugman Op-Ed: Hurray for health care
see Going Under c Goldilocks anesthesia.
youtube video, ‘Going Under with Goldilocks anesthesia’ has gone viral since being cited by Outpatient Surgery Magazine email blast & eweekly