Goldilocks Anesthesia Foundation

July 5, 1977, at Mt. Diablo Hospital in Concord, California, I stood ready to give my first anesthetic in private practice.

Several years earlier, on the very first day of his residency, on his first case, one of the Stanford residents had a child die from malignant hyperthermia (MH). (The antidote, Dantrolene, was not introduced until many years later.)

This unlucky resident’s liability insurance carrier even tried (but failed) to rate his private practice policy based on this hugely unfortunate experience.

My good fortune was to have started and finished my Stanford residency without ever seeing an MH case. However, I was hoping to get through my first private practice case without any such bad luck, too.

There I stood awaiting the arrival of plastic surgeon, Hale Tolleth, M.D. He was an hour late…

He introduced himself to me then explained the facial surgery case would take the whole day, but he did not want me to intubate the patient, ‘just’ sedate her.

There I was, prepared to anesthetize any cardiac case including a transplant but was being asked to provide a service about which I knew nothing.

During my residency, I had given intravenous sedation for cases as long as 45 minutes, typically with diazepam and meperidine.

I had never heard, read about, or had presented a ‘game plan’ of sedation for an 8 hour case.

Welcome to private practice, Dr. Friedberg, I thought.

After giving the problem some consideration, I guessed at what might provide the conditions for which my surgeon asked.

I took a 500cc bottle of saline, injected 500 mg thiopental and 100 mg meperidine, spiked the bottle with a 60 drop per cc set, gave some nasal oxygen & proceeded to titrate the patient.

She was in a semi-sitting position. The surgeon must have been very good with local anesthesia because I have no recollection of the patient moving or him re-injecting.

Another unique moment happened about half way through the case. Tolleth looked over to me and asked what I would like for lunch. I thought surely he must be teasing me. Having lunch was never a consideration during my 2-year residency.

I thought I would return the tease saying ‘lox and bagel would be just fine.’ To my astonishment, the surgeon told the nurse to fill my request and bring him his ‘usual.’

About 30 minutes later, in came the nurse with both lunch orders. My surgeon removed his gloves and we sat down and ate our lunch.

Never in the ensuing 34 years have I had such an experience.

Never lost the airway through the entire facelift, etc. case.

Needless to say, though, the patient was so hung over at the case’s end, she spent the night in the hospital. In 1977, no one thought it was an odd outcome after an 8-hour surgery.

However, I thought it would be really wonderful to have a drug that would go away after a case like that. Propofol was not introduced until 1989. We had no pulse oximeter until 1984.

As I think back over the triumphs and disasters through which I have persevered, I would have surely been incredulous if anyone would have told me I would author not one, but two books, receive a US Congressional award as recognition for contributing to the anesthesia safety of wounded troops in the forward units and create a non-profit foundation to promote patient awareness of the critical need for brain monitoring during anesthesia.

As the song goes, “What a long strange trip it’s been.”

Thank you for sharing this moment in history with me.

http://www.facebook.com/pages/Cosmetic-Surgical-Arts-Center/15199267983?sk=wall

Cosmetic Surgical Arts Center

Dr. Friedberg demonstrated his anesthesia technique with the BIS monitor today in our clinic. A breast reduction with augmentation and an arm lift was performed without narcotics or general anesthesia – a first in our clinic. She was awake and asking questions before the drapes were down.

We were thoroughly impressed with Dr. Friedberg’s commitment to patient safety and welcome him back in the future.

About Dr. Barry L. Friedberg, MD | Dr. Barry Friedberg – Cosmetic Surgery Anesthesia1

drfriedberg.com

Just heard from my pal who’s brother is being operated upon this April 2011 at Hoag Hospital in Newport Beach.

When the nurse came from the OR to talk to my pal, she told him all the anesthesiologists are using the BIS monitor on every case!

HALLELUJAH!!! Finally, the 21st century standard of care is being employed.

Maybe my efforts have finally paid off or maybe it was this tidbit:

In the April 11, 2011 issue of “Current Opinion in Anesthesiology,” they conclude: “Given the trivial cost of the BIS (brain monitor) and the proven benefits demonstrated in prospective randomized studies, we consider its use justified in every general anesthetic.”

As the Orange County anesthesiologist who first routinely used the BIS in December 1997, I am pleased for all patients, especially me should I be so unfortunate to be taken in for emergency surgery.

I would imagine their recovery room activities, along with the hospital’s bottom line, have been improved.

Now if they would only give the nifty fifty – 50 mg ketamine 3 minutes prior to incision, they could also dramatically improve postop analgesia.

Friedberg’s Triad

I. Measure the brain…no BIS lower than 45 with General Anesthesia

Hint #1: trend EMG as secondary trace

Hint #2: respond to EMG spikes as if they were heart rate or blood pressure changes

II. Preempt the pain…the ‘nifty 50’ – adult patients rx 50 mg ketamine 3 min prior to stimulation

Hint #3: Number of adult NMDA receptors independent of body wt

III. Emetic drugs abstain…no narcotics (opioids) or stinky gases (iso-, des- or sevo-flurane)

Hint #4: stinky gases are also oxidizing agents

Hint #5: BIS/EMG monitored propofol ketamine not just for cosmetic surgery

Here is orthopedic anesthesia specialist, Dr. Parson’s one-take, unrehearsed testimonial:

http://www.youtube.com/user/narkose3535?feature=mhum#p/a/u/1/r6O-stIHlgo

Today is the 19th anniversary of my first propofol ketamine anesthetic that was given at a Newport Beach plastic surgeon’s office!

Propofol ketamine is the ‘lemonade’ I made from Martha’s ‘lemon’ or avoidable demise.

Had it not been for this plastic surgeon’s refusing to allow me to use narcotics or smelly gases, I would have never been motivated to find an alternative anesthetic paradigm.

Little did I know, 19 years ago, how dramatically for the better that motivation would change the lives of my patients as well as my professional life.

Louis Pasteur said, ‘Luck favors only the prepared mind.’

So when I heard Charles Vinnik talk about Valium-ketamine anesthesia @ the Hyatt Newporter in December 1991, I was ‘prepared’ to seek an alternative.

My first insight was finding that sleep doses of propofol blocked ketamine hallucinations every bit as well as Vinnik’s Valium.

Later, once I saw that giving 50 mg ketamine (aka the ‘nifty fifty’) before injecting the patient would prevent surgeons from inflicting pain on their unconscious, helpless patients, it became a matter of conscience to no longer give narcotics or smelly gases for cosmetic surgery.

Incorporating the brain monitor in December 1997 allowed others to reproducibly create my paradigm as well as giving every patient a custom tailored experience as opposed to ‘one size fits most’ anesthesia.

However, it was not until I experienced the absence of pain for 4 days after my own total hip replacement in May 2008 that I realized the ‘nifty fifty’ was applicable to any time the skin is breached for surgery.

While writing ‘Getting Over Going Under’ to help the general public deal with anesthesia fears, Michael Jackson died from unsafe propofol administration. I knew that I needed to add comment about his avoidable death to my book.

Brain monitoring would have enabled Conrad Murray to tell the difference between the benzodiazepine and propofol effect in Michael Jackson’s body. Jackson would still be alive today had this monitoring been used on him.

Brain monitoring is the 21st century standard for anesthesia care & propofol ketamine is the safest anesthetic.

http://www.draprasad.com/blog/2011/02/15/increasing-safety-in-anesthesia-using-a-brain-monitor/

I’ve been providing propofol ketamine anesthesia for the 19 years and the past 13 of them with BIS monitoring. I have also been publishing many articles, letters, and an entire book, ‘Anesthesia in Cosmetic Surgery,’ for the profession. Coming to grips with my own anesthesia fears for my hip replacement surgery, I wrote ‘Getting Over Going Under, 5 things you must know before anesthesia,’ for the general public to constructively deal with their anesthesia fears.

In 1993, I published that sleep doses of propofol given before ketamine prevent bad dreams, etc., from ketamine. The drugs are not mixed but used separately for specific effects. The ketamine can be thought of as the ‘olive’ in the propofol ‘martini.’ Everyone who has followed my paradigm has had no problems in patients receiving ketamine.

Narcotic use has been completely eliminated, not merely reduced, because patients only need Tylenol or Toradol for postoperative discomfort. This worked nicely for my own total hip replacement nearly 3 years ago.

The cost of the BIS sensor is $20. The monitor is a one-time expense amortized over many years of use. Cost is not substantial considering the benefits of avoiding the risks of over medication (delirium, dementia & death). Making the monitor truly useful does require using EMG as a secondary trace, a minor adjustment apparently unknown to many anesthesia providers.

The main reason to use propofol is that it is an anti-oxidant, unlike the commonly used inhalational anesthetics that raise markers of inflammation. As to measuring blood levels of propofol – this is not nearly as relevant as directly measuring its effect in the brain, something the BIS monitor does very well.

The BIS monitor also helps to tell the difference between spinal cord movement and brain originated movement. This difference permits the correct treatment for the movement. Spinal cord movement merely requires more local anesthesia. Brain movement requires more propofol.

As for postoperative nausea and vomiting, propofol ketamine was cited by Dr. Christian Apfel in ‘Miller’s Anesthesia,’ (p. 2473) the # 1 anesthesia textbook as having the lowest published rate in high risk patients without the use of anti-emetics like Zofran. Apfel, the world PONV expert, further states, ‘As long as emetogenic agents (narcotics and inhalational anesthetics are given, the use of anti-emetics is of limited utility.’

Recall is not the principle value of BIS monitoring. Giving respect to your individual differences in drug tolerance and elimination of the nefarious practice of routinely over medicating you are the greatest values of measuring your brain.

It is your right to demand nothing less than brain monitoring for your anesthesia, irregardless of whether you are young or old. Unless the anesthesiologist is presented with the financial loss of your surgery, you will not get your wish granted.

You must learn whether or not your brain will be directly monitored before lying on the gurney on your way to the operating room. Download 3 free letters from www.drbarryfriedberg.com to help you deal with this critically important issue.

Brain monitoring is the 21st century standard of anesthesia care. Remember, you have to live with the long term consequences of your short term anesthesia care.

People magazine failed to accurately quote my comments. I also said it wouldn’t matter if Jackson swallowed propofol or if Santa Claus came down the chimney to give propofol, nothing would relieve Murray of his responsibility to have watched and monitored his patient.

The defense is desperately looking for the slightest technicality with which to bamboozle at least one gullible juror into ‘reasonable doubt’ & acquit Murray.

Recent attempts to rehab Murray’s public image to the potential juror pool show TV footage of him at his ‘poor folks’ clinic in Houston along with the statement that he has never been sued for malpractice. What utter nonsense. Only a smooth talking, charmer of a sociopath like Murray can go 25 years+ without ever being sued. The average anesthesiologist gets sued every 8 years.

The only credible representation Murray makes is one that can be independently verified. When Murray returned to Jackson’s bedroom to find Jackson’s pupils fixed & dilated, he had to know his patient was already brain dead. Everything afterwards (the useless CPR, calling 911 & insisting on CPR continuing on a dead person) was purely for show to make Murray appear like the caring physician he is most clearly not.

Murray is an absolute disgrace to the medical profession and does not deserve to be called ‘doctor.’ Sadly, even if convicted and faces the legal maximum penalty, it will be scant justice for the Jackson family.

My modest proposal is to use the public education message of my non-profit Goldilocks Anesthesia Foundation – no more anesthesia over medication deaths – to serve as a living memorial to Michael, yet one last way for him to help others like he so often did while he was alive.

Free download letters @ www.drbarryfriedberg.com. Real justice for Michael.

Congresswoman Giffords took several hours to awaken after her surgery and anesthesia, according to her surgeon Dr. Gerald Lemole, the chief of neurosurgery at the University of Arizona Medical Center in Tucson.

Curious minds want to know if she had a brain monitor (& if not, why not?) to directly measure the anesthetic effect on her already injured brain. Presumably, had a brain monitor been used, Giffords’ wake up would have been merely minutes instead of hours.

Although Dr. Lemole said Giffords was functioning at the same level as preoperatively, the lack of being able to verbally communicate with her precludes a full assessment of her neurologic function.

It is known that some previously normal people develop an Alzheimer’s like dementia after anesthesia that I am confident is a function of the nefarious practice of anesthesia over medication that must happen to avoid anesthesia under medication and awareness.

The routine practice of anesthesia over medication is readily avoided by the use of a brain monitor. Brain monitors are available in 75% of US hospitals yet they are only being used 25% of the time. Allowing anesthesiologists (and nurse anesthetists) to play Russian roulette with their patients’ brains is an outrageous and unacceptable situation in the 21st century.

With Goldilocks anesthesia, patients receive neither too much nor too little but just the right amount. Go to www.drbarryfriedberg.com to download 3 free letters to help you avoid anesthesia over medication and the risks of delirium, dementia and death.

Minimizing the Risks of General Anesthesia in Surgery

Jerry H. Trachtman, Attorney
(866) 735-1102 Ext 405

Posted by Jerry H. Trachtman
August 12, 2010 3:20 PM

This information is not intended to constitute advice or a recommendation relating to a particular medical condition or treatment. It is not a substitute for a consultation with your own medical professional.

According to a study reported in Anesthesiology (April, 2009), the journal of the American Society of Anesthesiologists, between 1999 and 2005 there were 2,211 anesthesia-related deaths in the United States. Of those deaths, almost half (47%) were the result of general anesthesia overdose.

On May 18, 2010, CNN published the story of a woman who woke up in the middle of major surgery. The first thing she heard was “Cut deeper, pull harder.” Although the general anesthesia she had received was insufficient to keep her unconscious, it kept her from screaming or even moving a finger. According to a study reported by the Mayo Clinic, about 1 or 2 people in every 1000 may wake up while under general anesthesia, which is known as “anesthesia awareness”. Although in most cases the person does not feel pain, some people do experience excruciating pain and develop long-term psychological problems.

Clearly, anyone who is about to undergo a surgical procedure under general anesthesia has good reason to question the anesthesiologist in advance of surgery, and to ask how the appropriate drug and its dosage will be determined in order to assure good quality anesthesia without the risk of an overdose. Too much anesthetic can result in death, temporary mental impairment, or permanent brain damage, and too little can result in anesthesia awareness. Unfortunately for us, the administering of general anesthesia appears to be as much an imprecise art as it is a science.

The word “anesthesia” can be defined as “loss of sensation or awareness”. Every day, thousands of people undergo surgery with the safe, effective use of anesthesia. Local anesthesia numbs a small part of the body, usually by injections or ointments. Regional anesthesia is the use of a local anesthetic to numb a larger part of the body by injecting the local anesthetic drugs near the nerve bundle affecting the desired area, with the effect of interrupting the signals between that area and the brain. Sometimes referred to as “blocks,” the most common regional anesthetics are epidural and spinal. General anesthesia is the inducing of a state of controlled unconsciousness accompanied by the absence of pain, the paralysis of the entire body, and loss of memory. During general anesthesia, drugs are injected into a vein or gases may be breathed into the lungs. Interestingly, the precise mechanism of general anesthesia is not yet fully understood, and research to understand it is ongoing.

General anesthesia is more than simply putting the patient to sleep. The loss of consciousness experienced in sleep, compared to the loss of consciousness induced by general anesthesia, is significantly different. When we fall asleep, our consciousness fades and we enter sleep cycles. These cycles are classified as either REM (rapid eye movement) sleep, when remembered dreams occur, or non-REM sleep, during which the sleeper may be drowsy and lose consciousness, or may even be in deep sleep, but dreams are more like short flashes and are usually not remembered. The sleeper passes through several stages during a typical sleep and several transitions between REM and non-REM sleep occur. When we sleep, our brain is in its most active state, organizing knowledge and memories.

On the operating table, the brain uses less oxygen and is less active. The general anesthesia applied before surgery needs to guarantee not only the loss of consciousness, but also sedation, immobility, the loss of memory, and the absence of pain. Since general anesthesia inhibits the parts of the brain which are required for REM sleep, anesthetized subjects do not have REM sleep and usually do not remember dreams. While sleep can be reversed by shaking or loud noises, general anesthesia is reversed only by eliminating the anesthetic drugs.

Traditionally, anesthesiologists are trained to monitor vital signs — the patient’s oxygenation (concentration of oxygen in the blood and inspired gas), ventilation (breathing), circulation (EKG, blood pressure, and heart rate) and temperature – in order to assess the depth and effectiveness of general anesthesia. By continuously monitoring the patient’s vital signs, together with the anesthesiologist’s clinical experience and judgment, the anesthesiologist determines if a correct amount of anesthetic is being administered to safely keep the patient unconscious. According to Barry L. Friedberg, MD, a Board Certified anesthesiologist who has been quoted in medical journals and anesthesia textbooks, and who has lectured on the subject to surgeons and anesthesiologists in the United States, Canada, Mexico, the Dominican Republic, Israel and Venezuela, anesthesiologists would be able to determine a more exact general anesthesia dosage if they would use a device known as a brain function monitor to more accurately monitor consciousness.

“The brain is the target for anesthesia. It’s critical for the brain to be measured with a brain activity monitor; however, most anesthesiologists are not doing this”, says Dr. Friedberg. “Brain monitoring doesn’t replace vital signs monitoring, but vital signs monitoring can’t give you the information that the brain monitor does,” he says. “Anesthesiologists were trained like I was years ago to believe that heart rate and blood pressure changes are a clue to what goes on inside the brain, but to make sure you give enough you always have to overmedicate by 20 to 30 percent. Using a brain monitor, of course, this type of practice becomes superfluous because it turns out that heart rate and blood pressure changes have almost nothing to do whatsoever with what’s going on in your brain.” “It’s a [$25.00 disposable] sensor that sits on the forehead and plugs into a computer and the computer generates a number from 0 to 100 that allows you to measure the individual response of each patient, so instead of a one size fits most you get a this size is your size for your operation today.” “Without a brain monitor, anesthesiology is not an exact science. With a brain monitor, each patient becomes an open book test instead of a mystery to be solved.” Dr. Friedberg emphasizes he does not make money by spreading this message, he does not have a financial interest in the monitor manufacturers, and he does not have an axe to grind with the drug companies. “We should focus on caring for patients, and understanding the long term risks of overmedicating patients while in surgery. We should be using every tool available to keep them healthy and reduce unnecessary risks through the entire treatment process.” “Nobody should have general anesthesia without a brain monitor. Most people don’t realize that if they don’t ask specifically, the anesthesiologist is not going to use it.”

Currently there are brain monitors available in almost half the operating rooms in the United States. Brain function monitoring technology is widely studied and widely accepted, and is supported by more than 3,300 published studies. The technology has been used on more than 34 million patients around the world, and is utilized in more than 80% of the top ranked US hospitals (according to US News and World Report ranking). However, there is controversy about the effectiveness of the use of brain function monitors.

Some studies claim there is no benefit in using brain function monitoring to prevent anesthesia awareness. Other studies suggest that the decision to use a brain function monitor should be made on a case-by-case basis by the anesthesiologist for selected patients, such as patients undergoing trauma surgery or cesarean section who cannot tolerate a deep anesthetic. Providing a lighter than normal anesthetic to at-risk patients may be a necessary step taken by the anesthesiologist. Advocates like Dr. Friedberg say brain monitoring is essential to ensure the patient achieves the appropriate level of anesthesia. Nevertheless, the American Society of Anesthesiologists foresees brain activity monitoring as a standard of care in the administration of general anesthesia.

Tags: surgery, anesthesia overdose, anesthesia awareness, brain monitor, brain function monitor

2 of 2 people found the following review helpful:
5.0 out of 5 stars

What you must know before receiving anesthesia, December 7, 2010
By Leslie (Midwestern USA) – See all my reviews

This review is from: Getting Over Going Under: 5 Things you Must Know before Anesthesia (Paperback)

Having elective surgery is a scary proposition for most people. We go to a trusted doctor or get a good referral, have a consultation to understand our options and even seek out a second opinion; but how much do we research the anesthesiologist, the person we trust to make sure we wake up after the procedure is over? For most people, not much research at all. Most patients meet the anesthesiologist the morning of the surgery and know very little about them. This book explains what everyone needs to know, what you must know, before receiving any anesthesia.

This is a subject I have a great interest in. Several years ago my mother received too much anesthesia during an elective surgery. Perhaps you know of someone, usually an elderly person, who had an operation and afterwards was never quite the same, had memory problems and then slowly declined losing their independence; dementia sets in. That’s what happened to my mom. The doctors say it’s one of those things that happens with older people after surgery. I don’t believe things like that `just happen’. After much questioning of the medical staff, a few individuals confided, off the record, that the cause was the anesthesia.

This experience set me on the path of discovery. For the past few years I have been reading everything I can on the subject of anesthesia and it’s effects on patients. I was determined to never let this happen to anyone again if I could prevent it. That meant educating myself on the subject.

Recently I discovered Getting Over Going Under by Dr. Barry Friedberg, an anesthesiologist. This book was exactly what I was looking for. Dr. Friedberg explains in layman’s terms how anesthesia works and what it does to the brain and the body. It’s written for the patient in an easy to understand manner. He explains how traditionally doctors medicate the brain using a best guess dosage of drugs based on patient height and weight. The result of over or under anesthesia can cause a range of problems from patient discomfort and disorientation to hallucination, dementia and even death.

Dr. Friedberg’s “Goldilocks” method of anesthesia uses a brain monitor to determine the exact dosage for each patient by monitoring the brain while the patient is under. Perhaps I was naive, but I assumed hospitals were already doing that. Per Dr. Friedberg, most hospitals do not use a brain monitor even if the equipment is available. “The brain monitor”, says Dr. Friedberg, “allows the anesthesiologist to know with certainty whether more or less anesthesia is needed”. There are a variety of reasons, including pharmaceutical company profits, that most doctors don’t use the brain monitor. Old habits are hard to break and new techniques are slow to be put into use.

In easy to understand steps the book outlines what patient can do to safeguard their own health. Dr. Friedberg reviews the five things you must know before anesthesia and gives useful tips on how to talk to your doctor. This book is an invaluable tool to educate patients. No one cares about you as much as you do. You have the right to ask for the high-quality care you deserve.

Source: Review copy provided by author.