BIS Monitoring Transformed Opioid-Free Propofol Ketamine Anesthesia From Art to Science for Ambulatory Cosmetic Surgery
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BIS Monitoring Transformed Opioid-Free Propofol Ketamine Anesthesia From Art to Science for Ambulatory Cosmetic Surgery Barry L. Friedberg1
Received: 28 May 2020 / Accepted: 20 September 2020 Ó Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2020
Abstract Measurement is the essence of science. The BISTM brain monitor provides direct propofol response measurement. Measuring transformed the propofol ketamine technique from a qualitative approach to a quantitatively reproducible one. Propofol was originally titrated with an IV bag and a micro-drip IV set. Propofol response was titrated to clinical signs. An infusion pump later replaced the IV bag, enabling the propofol dose enumeration. The propofol effect was measured with a BIS.TM A statistically significant 30% propofol reduction was achieved with BISTM monitoring. Patient movement occurred during propofol sedation. Secondary EMG trending to BISTM enabled the differentiation of cortically based movement (i.e., deeper sedation indicated) from spinal cord-based movement (i.e., more local indicated). Outcomes were improved when surgeons re-injected vasoconstricted field with patient movement.
Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00266-020-01987-6) contains supplementary material, which is available to authorized users. & Barry L. Friedberg [email protected] 1
Goldilocks Anesthesia Foundation, 15 White Cap Drive, Corona del Mar, CA 92625, USA
Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
Introduction Ambulatory cosmetic surgery patients are expected to be discharged to home following their surgery. The problems facing their anesthesiologists and surgeons are (1) delayed emergence, (2) pain, and (3) postoperative nausea and vomiting (PONV). These problems are causes for unintended hospital admission after day surgery. Ambulatory discharge is predicated on discharge-ready emergence in about an hour after surgery. When patients take longer to emerge, discharge is delayed, resulting in increased nursing hours and decreased cost-effectiveness. Discharge delays secondary to patients’ rides are a different issue but not in the purview of the anesthesiologist. A patient’s brain cannot respond to information it does not receive. Failure to saturate N-methyl-D-aspartate (NMDA) receptors prior to local anesthetic (LA) injection is a major cause of postoperative pain [1]. From March 26, 1992, to December 26, 1998, after a qualitative, incremental propofol induction, a 50 mg IV ketamine dose was given 2–50 before the surgeon’s LA. The 2–50 delay allows the ketamine to saturate the NMDA receptors. The saturation provides 10–200 immobility for LA injections. After the initial LA injections, patient m
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