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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.
Anesthesia awareness is not lethal but anesthesia over medication, the natural consequence of failing to monitor depth of anesthesia, IS, specifically to the tune of one American patient every day!
Li G, et al: Epidemiology of Anesthesia-related Mortality in the United States, 1999–2005. Anesthesiology 2009;110:759
By trending EMG as a secondary trace, one creates a real time BIS monitor. Responding to spikes in EMG activity as if they were HR or BP changes is the key.
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.
Universal BIS/EMG monitoring would reduce anesthesia drug usage by 30% – a big hit to anesthesia drug makers who, in turn, provide millions of various forms of support dollars to organized anesthesia.
Friedberg BL, Sigl JC: Clonidine premedication decreases propofol consumption during bispectral (BIS) index monitored propofol-ketamine technique for office based surgery. Dermatol Surg 2000;26:848-852.
Every ‘anesthesia awareness’ article is a political statement by organized anesthesia:
“We are for patient safety…
ONLY as long as it doesn’t screw with the drug company money.”
Stop drinking the Kool Aid & stop the epidemic of anesthesia over medication…
Disclaimer: Neither I, nor my non-profit Goldilocks Anesthesia Foundation, receive financial support from brain monitor or drug makers.
We do not blame the automobile for the reckless drunk driver’s deaths. By his own public admission, Conrad Murray was reckless by giving Jackson propofol & leaving the room.
Hundreds of millions of patients worldwide have safely received propofol because someone was watching them breathe & monitoring their oxygenation.
Many medically licensed practitioners, nurses & physicians alike, have learned how to safely give propofol by taking this online course @ conscious sedation to learn how to combine direct brain measurement with pulse oximetry.
Conrad Murray was practicing as a cardiologist with hospital privileges to catheterize & stent diseased coronary arteries under propofol sedation & pulse oximetry. Despite this knowledge, he chose to buy the cheapest pulse oximeter monitor for Jackson – one that made no sounds & had no alarms.
Clearly, Murray does not believe the normal safety measures apply to his practice, behavior that defines him as a sociopath that never again deserves a license to practice medicine.
Virtually every cosmetic surgery begins with the injection of epinephrine in lidocaine solution.
Epinephrine provides shrinkage of the blood vessels (vasoconstriction) that minimizes blood loss during surgery.
Lidocaine can provide adequate pain relief (analgesia).
Since both drugs are given in the same syringe, having observed vasoconstriction, the surgeon ‘reasonably’ concludes the problem must be in the level of sedation when the patient moves during surgery.
Prior to the ability to directly measure the patients’ brain response to anesthesia, every patient movement necessitated more (& different) sedative treatment to insure no awareness or recall was responsible.
This practice led to excessive & erroneous medication of patients, leaving some with postoperative nausea & vomiting (PONV), pain or even post-op delirium.
With the advent of direct patient movement, the surgeon can make the differential diagnosis of more lidocaine or more propofol, leading to the more correct treatment.
Correctly treating the real cause of patient movement (inadequate local analgesia), avoids the need for excessive (or wrong) drugs, like narcotics, being given to patients & a far better postoperative outcome for all involved.
Direct brain monitored propofol sedation is the 21st century standard of care.
Be sure to ask if this will be done for your cosmetic procedure.
No surgery under anesthesia without a brain monitor
Would be honored if you would consider sharing this information with your network of colleagues, friends & trainees.
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.