DOSE & TIMING ESSENTIAL TO TRIUMPH OVER POSTOP PAIN

Dose & timing as the essential 'secret' to avoiding creating intra-operative pain, wind-up & postoperative pain management. Never once in the first 15 years of my career did I wonder why patients needed opioid rescue for postop pain. After observing 50 consecutive propofol ketamine cases emerge without such need did I conclude postop pain was a function of intra-op pain something I thought I had been doing.

The brain cannot respond to information it does not receive. However, if the only manner in that we believe the brain has been protected from pain is the absence of heart rate (HR) or blood pressure (BP) response to skin incision, then pain management will always be a problem post-operatively.

HR & BP are primary brain stem functions with unreliable guides to cerebral cortical response. Pain and consciousness are higher, cortical functions. Trending EMG as a secondary BIS trace provides a real time, useful guide to the presence or absence of cortical response to skin incision or multiple local anesthetic injections.

For elective surgery cases, please watch YouTube Going under with Goldilocks anesthesia to see how to create a stable CNS propofol level to block negative ketamine side effects. Incrementally titrate propofol to 60<BIS<75 with baseline EMG (i.e. 30 on the left hand BIS scale, 0 on the right hand EMG scale). Inducing in this manner avoids hypotension &/or airway loss with avoidable stress to the anesthesia provider, surgeon and OR personnel.

Once induction is performed, secure the airway as needed, then give 50 mg ketamine independent of body weight 2-3 minutes prior to incision. Dose & timing essential for success!

50 mg ketamine will block 98-99% of adult midbrain NMDA receptors, depriving the brain of the knowledge that the world of danger has invaded the protected world of self!

Having used this numerically reproducible paradigm for the past 20 years in >6,000 patients, there have been NO hospital admissions for postoperative pain management.

As a bonus, opioid avoidance produced the lowest published PONV rate (0.6%) in an Apfel-defined, high risk patient population without use of anti-emetics. Friedberg BL: Propofol-ketamine technique, dissociative anesthesia for office surgery: a five-year review of 1,264 cases. Aesth Plast Surg 1999;23:70-74, subsequently cited by Apfel PONV ch. in both 2010 & 2015 eds. of Miller's Anesthesia!

To recap, allowing surgeons to perform a skin incision (btw, procedure irrelevant) without NMDA block, is allowing the inadvertent infliction of pain, resulting in the need for multi-modal postop pain management. Our duty, as anesthesiologists (nurse anesthetists or anesthesia assistants), is prevention of pain. Why continue to subject patients to pain when $0.70 worth of ketamine given preemptively can do so much good? Giving the ketamine after skin incision is like closing the barn doors after the horses have left.

Consider watching 14" YouTube Goldilocks anesthesia lecture now having been watched >1100X worldwide for more information.

Disclaimer: Neither I, nor my nonprofit Goldilocks Foundation, receive financial support from BIS maker.

PS EMG spikes persist in the presence of neuromuscular block (NMB) &/or BOTOX. Absence of EMG spike with incision is evidence of NMDA block.