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.

Alan Tallmeister, MD
Unionville
Ontario, Canada
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Dear Barry,

Just a quick note to say hello again and to let you know of my latest exploits with PKRASV. I had a case some time ago of an elderly lady who was a pulmonary cripple for segmental mastectomy. Did her under PKRASV, worked great. Wrote the case report and it was accepted for publication in American Journal of Anesthesiology- but the journal just folded before it could be printed! I was just a little too late, I guess.

Anyway, I did another case today for colonoscopy. The GI doc called me to do the case because she had "failed" under prior sedation regimens by non-anesthesiologists. A little ketamine and propofol, and next thing I knew, the case was done, the patient was laughing and joking, and the GI doc was in my gratitude. It's nice to have a tool that works so well!

Thanks, and keep it up-

Skip Culp

Barry,

I've been using propofol with ketamine for 4-5 years now. Initially I mixed them in the same syringe, but about a year ago I started using 25-50 mg ketamine boluses separately. It works great as a supplement to MAC for breast biopsies and hernia repairs. I also use it for a laundry list of procedures that do not lend themselves to "conventional" MAC, things like closed reductions, lithotripsy, debridements. I used it last week on a woman who dislocated her jaw and had her mouth jammed open. Also used it last week for an open ankle reduction on an anticoagulated patient with a fresh MI (his heart rate and blood pressure never changed from baseline). It is the answer to every anesthesia question. Many of the surgeons now request the technique. None of the patients has had any complaint; although some have noted particularly pleasant experiences.

Steven Schrenzel MD
Media, PA
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Just a follow up. We have performed well over 1000 anesthetics for out patient neurosurgery cases using a modification of the PK in the last 11 months. No admissions, VERY infrequent nausea and only one episode of vomiting. (this in a diabetic with severe gastroparesis and regurg preop) We do modify your described anesthetic protocol using "BKK" infiltrated prior to and with closing the incision, and have come up with additional "tricks" using inexpensive old reliable off patent agents. BKK is .25% marcaine with epi (1:400,000,ketolorac0.1mg/cc,ketamine0.5mg/cc) Typically our patients verbal pain scores are 4 to 5 with in 3 minutes of extubation. Load po hydrocodone 10 to 20 mg as soon as swallowing safely. 90 to 95% of our patients bypass level one recovery. Our patients are fully ambulatory, void, and tolerate po fluids prior to home discharge. Average pain score 1 to 2, never discharged with a score higher than 5 by protocol. Our "record" d/c time post extubation is 47 minutes male, 43 minutes female.

Our propofol and inhalational agent costs are incredibly low. In addition very infrequent antiemetic need relates to lower total formulary and fluid costs, not to mention the staffing costs. Our turn over times average 3 to 4 minutes. Our surgeons are very happy and tired of the patients commenting "how wonderful we are". The only complaint from our staff has been lack of over time (1.5 x standard pay). I am crunching the numbers for our lumbar lam, posterior cervical lam, and anterior cervical lam/fusion patients and hope to have some meaningful hard data soon. Your thoughts on where to submit for publication?

Brad Worthington
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