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www.doctorfriedberg.com |
June 2002
Letter to Dr. Friedberg
Dear Dr. Friedberg,
I first learned of this propofol ketamine (PK) technique several years ago when I posted the dilemma of patients of a certain cosmetic surgeon with whom I worked. This colleague attributed his post-op problems (facial hematomas and wound dehiscences) to anesthetic techniques.... namely relatively low BP intraop with subsequent BP rise on emergence and extubation causing bleeding as well as straining on extubation causing wound suture dispuption.
Before trying it out, I obtained printed literature on this method after Dr. Friedberg suggested his technique. I have had very good results. The cosmetic surgeon now attributes his suboptimal outcomes on less-than-ideal O.R. equipment as well as patient factors. However, the patients awaken quickly post-op, often amazed to find out everything was completed and that two or three hours had elapsed. Recovery and day surgery nurses also were impressed.
There is a bit of puzzlement how to class the anesthetic...whether “neurolept” or “general”. I tell them check off “general”, since the patient is non-rousable while the Propofol drip is running, although without local anesthetic it may not have worked as impressively. As it turns out, the cosmetic surgeon for whose patients I first began to use this technique hasn’t booked many cases suitable to this technique in the intervening years. Nonetheless, I’ve adapted the method to a variety of other procedures much more frequently performed at my home hospital.
(1). Morbidly obese patients. No....not for the gastroplasty and/or bypass, but for some minor procedures occasionally done post-op before the patients begin to lose much weight. In the laparoscopically banded procedures occasionally the injection port needs to be re-sutured or alternatively adjusted. In open procedures, wounds occasionally get superficial infection. The surgeons have tried local only but quickly gave it up. The PK method is ideal...maintenance of spontaneous breathing and airway (O.K. a bit of mandibular support on occasion), good surface analgesia and immobility for the surgeon. Many of these patients have awoken reporting a feeling of euphoria and well-being.
(2). Hemorrhoid surgery in prone position. A new surgeon learned this in residency...better exposure and less bleeding than supine-lithotomy or lateral positions...and it’s caught on with other general surgeons. Where she trained, the anesthetists have boluses of fentanyl and midazolam. I was already comfortable with PK so used this, letting the patient self-position while awake, then titrating to sleep with propofol and giving ketamine just before the local. Patient awaken prone and obligingly turns onto side on the recovery room gurney parked next to the OR table. Works equally well for pilonidal cyst excisions. I find these patients are often obese, sedentary types and I’m glad not to have to intubate and then flip over (and later back) 100+ Kg. of dead weight and flopping appendages.
(3). Many superficial procedures where muscle relaxant isn’t needed and local can be infiltrated. Many breast excision biopsies and simple hernia repairs fall into this category. If it’s not sufficient, then it’s no big deal to switch to inhalational anesthetic and insert LMA or even inject a reduced propofol dose and intubate.
(4). I’ve begun to do knee arthroscopies by this method. One orthopod needed reassurance that he could proceed when he saw a patient lying there without a tube or LMA in the mouth breathing room air and when I told him that it WASN’T a spinal.
Anesthetic colleagues also ask whether my patients don’t emerge dysphoric or delirious from ketamine, a drug they regard as akin to L.S.D. I explain that it can happen when ketamine is used “solo” in large doses (even then not that often or severely), but as a dissociative agent given to an already unconscious patient, it’s a non-issue. I remind some of them that they routinely reverse each and every patient...generally employing neostigmine and atropine...a far worse culprit in producing delirium.
(5). I had an ortho list yesterday.... total knee and then several ganglia, a carpal tunnel and some knee ‘scopes. The first case was spinal, the rest were PK with local by the surgeon. Supplemental O2 was required neither post-op nor for that matter intraop in any of these patients. Hate to say there are still lots of colleagues around who’d have intubated and ventilated each of these patients, likely lugging some of them into recovery room still intubated. Sore throats, achy muscles, several extra hours of recovery time and nursing hours, perhaps even an unscheduled overnight admission, even if worse problems such as traumatic intubations or bobbled extubations followed by laryngospasm and negative-pressure edema didn’t occur.
Sincerely,
Alan Tallmeister, MD
Unionville
Ontario, Canada