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.

Memory Loss after Surgery

In response to  https://www.washingtonpost.com/national/health-science/what-we-know-and-dont-know-about-memory-loss-after-surgery/2018/04/12/0b7e32da-3e32-11e8-955b-7d2e19b79966_story.html?noredirect=on&utm_term=.fa9859ba0747

As a 40-year practicing, board-certified anesthesiologist, I was an early adopter of the 1996 FDA approved BIS brain monitor to directly measure my patients’ brain response to propofol effects under anesthesia. Prior to 1996, only brain stem signs (heart rate & blood pressure changes) guided anesthesia dosing. Pain & the awareness of consciousness are processed at higher brain levels; i.e. the cerebral cortex.

In 2000, I published a statistically significant 30% reduction when using this monitor compared to relying on brain stem signs. (Friedberg BL: Dermatol Surg 2000;26:848.) Big Pharma has no financial interest in any reduction of anesthetic drug use. Dr. Cole is also the past president of the American Society of Anesthesiologists (ASA) that receives substantial financial support from Big Pharma. The ASA continues to resist recommending BIS monitoring for major surgery under anesthesia. A clear conflict of interest exists between patients’ getting the best available technology to avoid over medication and the financial underpinnings of the ASA.

There may be many reasons for POCD. However, it makes no sense to continue to over medicate patients by 30%, especially for patients over 50 like Dr. Cole’s father. (Friedberg BL: Br J Anaesth Sep 28, 2015;115:i114-i121)

The goal of my nonprofit Goldilocks Foundation is making brain monitoring a standard of care for major surgery under anesthesia. Patients will be better able to advocate for this monitor by downloading a free copy of ‘Getting Over Going Under, 5 things you MUST know before anesthesia’ from the foundation web site. No ‘donate’ or ’email’ buttons when downloading.


Disclaimer: Neither I, nor my nonprofit foundation receive BIS maker financial support.



Opioids are not the answer. Opioids are the problem.

Opioid free anesthesia leaves the patient in better postoperative condition than reducing intra-operative opioid use.

50 mg IV ketamine 2-5 minutes pre-skin stimulation saturates midbrain NMDA receptors providing opioid free preemptive analgesia.

Dose & timing essential!

Incrementally titrated propofol to BIS <75 with baseline EMG provides a stable CNS level of propofol to ward off ketamine associated negative side effects.

The magic interval (i.e. after 50 mg IV ketamine 2-5” pre-incision) between the time the cortex was denied knowledge of the surgeon’s invasion of the body (i.e. skin incision) and the time it understands the invasion has occurred is ‘magical’ because healing takes place during that interval with a dramatic decrease in postoperative analgesia requirements.

FWIW, recently spoke with a PACU RN who, interestingly enough, had worked with me in a local plastic surgeon’s office over 14 years ago & saw Goldilocks anesthesia up close & personally. Ran into her at my local hospital & she told me they were experiencing a dihydromorphone (Dilaudid®) shortage &, as a result, the anesthesiologists have been using ketamine instead.

She noted the patients were coming to PACU in much better condition. Who’d have thought? <sarcasm>

Watch my talk from the European Society for Perioperative Care of Obese Patients (ESPCOP) & Opioid Free Anesthesia meeting in Bruges, Belgium Dec. 16, 2017

Opioid Free Goldilocks Anesthesia Lecture…    https://youtu.be/hTFK4SCVZtQ

Why ignore an unparalleled 25-year success in >6,000 patients without a single hospitalization for pain or PONV?



Liposuction Death in Miami/Response


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.


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.


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.”


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 NA– USEA, 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.



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.


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.