**5. Putting brain monitored propofol ketamine ("Goldilocks") anesthesia into practice**

*Teaching the technique is simple. Teaching cooperation is not.*

*Daniel HS Lin, DO, Cosmetic surgeon*

Along with the patient, many egos enter the operating room, not the least of which is that of the surgeon's. The surgeon's cooperation with local anesthesia is essential for success. The surgeon must also understand the need for *adequate* local anesthesia. **Surgeon perfection injecting local analgesia is not a requirement, only persistence.** Surgeons typically equate a blanched surgical field with adequate analgesia. Only with brain monitoring can the anesthesiologist hope to convince the surgeon that a blanched field only equals adequate vasoconstriction.

that it is resolved when the ointment is wiped from their eyes. One patient in the author's 40-year career became panic-stricken upon emergence thinking something bad had happened to her eyes. Full disclosure to avoid repetition of this unfortunate patient's experience

Brain Monitored Propofol Ketamine for Elective Cosmetic Surgery

http://dx.doi.org/10.5772/intechopen.71442

49

Ketamine increases salivation. Glycopyrrolate causes less tachycardia and, for that reason, is chosen as an antisialagogue in preference to atropine. Because propofol can sometimes cause patient discomfort, lidocaine is added to the glycopyrrolate. The patient is advised to tell the anesthesiologist if there is additional aching during induction so that more lidocaine can be

Between 1992 and 1997, a 50-ml IV bag with 400 mg (40 ml) propofol was connected to a 60 drops/ml IV set (mini-drip, pedi-drip, micro-drip). The initial rate was set to the patient's heart rate and adjusted until **loss of lid reflex** and **loss of verbal response** were observed. This was a **qualitative** approach that was far more subjective and less reproducible. After the demand for the propofol numbers for publication, the author began using an infusion pump. A completely programmable, albeit more expensive, infusion pump is better than less expensive, commonly found pumps that only permit settings of 25, 50, 75 or 100 mcg/kg/min. The ability to deliver a separate bolus in addition to maintaining an infusion rate is also important. This **quantitative** approach along with BIS/EMG monitoring makes "Goldilocks" anesthesia

Set the pump to deliver propofol for 50 mcg/kg minibolus. Induce with miniboluses given in *one after another* until a decrease in the real-time frontalis muscle electromyogram (EMG) is observed (see YouTube Going under with Goldilocks anesthesia). The BIS value and trend line will display behind the EMG as it is based on algorithm-derived information that is delayed

The induction goal is to observe whether or not 25 mcg/kg/min basal infusion rate is sufficient to maintain 60 < BIS < 75 with baseline EMG. Bolus with 50–100 mcg/kg to maintain BIS <75 and upwardly adjust the basal propofol rate to 35–50 mcg/kg/min to maintain that level PRIOR to administering ketamine. Most patients have been maintained at 60 < BIS < 75 with baseline EMG with propofol 25–50 mcg/kg/min. However, as little as 2.5 mcg/kg/min and as much as 200 mcg/kg/min propofol have also been observed by the author in his 20-year, >4000

Avoid the textbook advice of 1–2 mg/kg propofol bolus for induction. A bolus will produce peak propofol levels in the brain quickly and just as quickly begin to redistribute, decreasing a protective level just as the ketamine arrives to the brain. The brain may then not be protected from ketamine side effects when that drug is administered. The value of the brain monitored, incremental induction is providing a **numerically reproducible, stable propofol brain level to prevent negative ketamine side effects** [13]. The very sensitive as well as the very resistant patient can be identified from the outset of the case rather than trying to understand a body weight–derived dose effect. Lastly, the incremental propofol induction preserves baseline blood pressure as well as the muscles that maintain a patent airway*, i.e. the temporalis, masseter, orbicularis* and *genioglossus*. Nevertheless, one must always be prepared with available bag mask ventilation and suction for the exceptional patient, no matter how often it will be unnecessary.

administered. Propofol ache is more common with distally placed IV.

is strongly recommended.

numerically reproducible.

from real time by 15–30 s.

patient clinical experience.

Prompt essentially PONV free and minimal pain recovery are the hallmarks of "Goldilocks" anesthesia. Once the surgeon observes how much better his patients do postoperatively, the need for his/her cooperation should become apparent. The office-based setting has a higher incentive for surgeon cooperation. Recovery space is limited and personnel are often multitasked compared with free-standing or hospital-attached day surgery center facilities. As superior and **numerically reproducible** as the "Goldilocks" anesthesia outcomes are, there are still surgeons reluctant to cooperate. Just as disappointing is the numbers of anesthesiologists who remain shackled to the outdated teachings that ketamine causes hallucinations, hypertension and tachycardia or are unwilling to reconsider using real-time BIS/EMG to titrate propofol.

The clinical pathway for brain monitored propofol ketamine ("Goldilocks") anesthesia is a simple straightforward three-drug technique: glycopyrrolate, propofol and ketamine. Induce hypnosis first, next dissociate, then inject local analgesia (**Table 4**). (Atropine may be substituted when glycopyrrolate is unavailable. Tachycardia will more commonly result than administering glycopyrrolate). Unexplained tachycardia, not temperature elevation, is the cardinal recognition sign for MH. Once the brain is protected with propofol incrementally titrated to loss of lid reflex/loss of verbal response or 60<BIS<75 with baseline EMG, the 50mg ketaamine by itself does not cause tachycardia or hypertension!

Prior to placing the BIS sensor on the forehead, the patient is advised **the number from their forehead allows them to "control" their anesthetic dose**. This control means that neither too much nor too little can be given. Then the patient is encouraged to touch the sensor pad to assure them their skin cannot be scarred even though the sensor application will be a little uncomfortable. A small discomfort for a great relief about anesthetic dosing is greatly appreciated by patients. Patients are additionally advised that 5% or one in 20 may have pleasant, colorful dreams.

The preoperative consultation includes disclosure of the dry mouth and the need to maintain eye lubrication with ointment. Patients are told to expect blurry vision upon awakening and

Propofol infusion rate start 25 mcg/kg−1/min−1

Adjust infusion rate as needed to maintain 60 < BIS < 75 with baseline EMG

Ketamine 50 mg IV 3 minutes prior to local analgesia injection

Lidocaine 1 mg/lb−1 or 2 mg/kg−1 IV STAT for laryngospasm

Labetalol 10 mg iv for HR > 100–110. Avoid if patient asthmatic

**Table 4.** Clinical pathway.

Glycopyrrolate 0.2 mg with 30 mg lidocaine IV

Propofol 50–100 mcg/kg−1 minibolus repeated to 60 < BIS < 75 with baseline EMG

that it is resolved when the ointment is wiped from their eyes. One patient in the author's 40-year career became panic-stricken upon emergence thinking something bad had happened to her eyes. Full disclosure to avoid repetition of this unfortunate patient's experience is strongly recommended.

equate a blanched surgical field with adequate analgesia. Only with brain monitoring can the anesthesiologist hope to convince the surgeon that a blanched field only equals adequate

Prompt essentially PONV free and minimal pain recovery are the hallmarks of "Goldilocks" anesthesia. Once the surgeon observes how much better his patients do postoperatively, the need for his/her cooperation should become apparent. The office-based setting has a higher incentive for surgeon cooperation. Recovery space is limited and personnel are often multitasked compared with free-standing or hospital-attached day surgery center facilities. As superior and **numerically reproducible** as the "Goldilocks" anesthesia outcomes are, there are still surgeons reluctant to cooperate. Just as disappointing is the numbers of anesthesiologists who remain shackled to the outdated teachings that ketamine causes hallucinations, hypertension and tachycardia or are unwilling to reconsider using real-time BIS/EMG

The clinical pathway for brain monitored propofol ketamine ("Goldilocks") anesthesia is a simple straightforward three-drug technique: glycopyrrolate, propofol and ketamine. Induce hypnosis first, next dissociate, then inject local analgesia (**Table 4**). (Atropine may be substituted when glycopyrrolate is unavailable. Tachycardia will more commonly result than administering glycopyrrolate). Unexplained tachycardia, not temperature elevation, is the cardinal recognition sign for MH. Once the brain is protected with propofol incrementally titrated to loss of lid reflex/loss of verbal response or 60<BIS<75 with baseline EMG, the 50mg

Prior to placing the BIS sensor on the forehead, the patient is advised **the number from their forehead allows them to "control" their anesthetic dose**. This control means that neither too much nor too little can be given. Then the patient is encouraged to touch the sensor pad to assure them their skin cannot be scarred even though the sensor application will be a little uncomfortable. A small discomfort for a great relief about anesthetic dosing is greatly appreciated by patients. Patients are additionally advised that 5% or one in 20 may have pleasant,

The preoperative consultation includes disclosure of the dry mouth and the need to maintain eye lubrication with ointment. Patients are told to expect blurry vision upon awakening and

ketaamine by itself does not cause tachycardia or hypertension!

Propofol 50–100 mcg/kg−1 minibolus repeated to 60 < BIS < 75 with baseline EMG

Adjust infusion rate as needed to maintain 60 < BIS < 75 with baseline EMG

Ketamine 50 mg IV 3 minutes prior to local analgesia injection Lidocaine 1 mg/lb−1 or 2 mg/kg−1 IV STAT for laryngospasm Labetalol 10 mg iv for HR > 100–110. Avoid if patient asthmatic

vasoconstriction.

48 Anesthesia Topics for Plastic and Reconstructive Surgery

to titrate propofol.

colorful dreams.

**Table 4.** Clinical pathway.

Glycopyrrolate 0.2 mg with 30 mg lidocaine IV

Propofol infusion rate start 25 mcg/kg−1/min−1

Ketamine increases salivation. Glycopyrrolate causes less tachycardia and, for that reason, is chosen as an antisialagogue in preference to atropine. Because propofol can sometimes cause patient discomfort, lidocaine is added to the glycopyrrolate. The patient is advised to tell the anesthesiologist if there is additional aching during induction so that more lidocaine can be administered. Propofol ache is more common with distally placed IV.

Between 1992 and 1997, a 50-ml IV bag with 400 mg (40 ml) propofol was connected to a 60 drops/ml IV set (mini-drip, pedi-drip, micro-drip). The initial rate was set to the patient's heart rate and adjusted until **loss of lid reflex** and **loss of verbal response** were observed. This was a **qualitative** approach that was far more subjective and less reproducible. After the demand for the propofol numbers for publication, the author began using an infusion pump. A completely programmable, albeit more expensive, infusion pump is better than less expensive, commonly found pumps that only permit settings of 25, 50, 75 or 100 mcg/kg/min. The ability to deliver a separate bolus in addition to maintaining an infusion rate is also important. This **quantitative** approach along with BIS/EMG monitoring makes "Goldilocks" anesthesia numerically reproducible.

Set the pump to deliver propofol for 50 mcg/kg minibolus. Induce with miniboluses given in *one after another* until a decrease in the real-time frontalis muscle electromyogram (EMG) is observed (see YouTube Going under with Goldilocks anesthesia). The BIS value and trend line will display behind the EMG as it is based on algorithm-derived information that is delayed from real time by 15–30 s.

The induction goal is to observe whether or not 25 mcg/kg/min basal infusion rate is sufficient to maintain 60 < BIS < 75 with baseline EMG. Bolus with 50–100 mcg/kg to maintain BIS <75 and upwardly adjust the basal propofol rate to 35–50 mcg/kg/min to maintain that level PRIOR to administering ketamine. Most patients have been maintained at 60 < BIS < 75 with baseline EMG with propofol 25–50 mcg/kg/min. However, as little as 2.5 mcg/kg/min and as much as 200 mcg/kg/min propofol have also been observed by the author in his 20-year, >4000 patient clinical experience.

Avoid the textbook advice of 1–2 mg/kg propofol bolus for induction. A bolus will produce peak propofol levels in the brain quickly and just as quickly begin to redistribute, decreasing a protective level just as the ketamine arrives to the brain. The brain may then not be protected from ketamine side effects when that drug is administered. The value of the brain monitored, incremental induction is providing a **numerically reproducible, stable propofol brain level to prevent negative ketamine side effects** [13]. The very sensitive as well as the very resistant patient can be identified from the outset of the case rather than trying to understand a body weight–derived dose effect. Lastly, the incremental propofol induction preserves baseline blood pressure as well as the muscles that maintain a patent airway*, i.e. the temporalis, masseter, orbicularis* and *genioglossus*. Nevertheless, one must always be prepared with available bag mask ventilation and suction for the exceptional patient, no matter how often it will be unnecessary.

Only after the patient's propofol level has stabilized should the 50 mg ketamine, **independent of body weight**, be given, **3 minutes prior** to local analgesia injection. Any patient movement accompanied with an EMG spike during injection must be given more propofol to drive the EMG spike back to the baseline. As little as repeated 100 mcg/kg propofol boluses or as much as 200–400 mcg/kg propofol boluses may be required. An upward basal rate should be considered to maintain the patient's propofol level at 60 < BIS < 75 *with* baseline EMG.

saturation occurs. "Goldilocks" anesthesia provides numerically reproducible propofol levels to define adequate hypnosis as well as the absence of EMG spikes with local anesthesia injec-

Brain Monitored Propofol Ketamine for Elective Cosmetic Surgery

http://dx.doi.org/10.5772/intechopen.71442

51

Propofol ketamine is like the martini cocktail wherein the propofol is the 'vodka' and the ketamine is the 'olive.' Ketofol is when the propofol in mixed with the ketamine. These are two very different approaches that should never be confused with one another. **Do not mix** 

Propofol hypnosis is protective of ketamine hallucinations [13]. **Do not give ketamine before propofol hypnosis.** Bolus propofol induction will not provide a stable CNS propofol level to protect against ketamine hallucinations. Do not induce with 1–2 mg/kg propofol

Propofol at BIS < 75 with baseline EMG is a numerically reproducible protection against ket-

**Adequate local analgesia is critical** to minimizing or eliminating the need for postoperative opioid pain rescue. Do not fail to have the surgeon reinject the immediate area of dissection when patient movement occurs *without* EMG spike and BIS < 75. More propofol or ketamine is an inadequate response for patient movement at BIS < 75 with baseline EMG. Adding opioids instead of more local analgesia is not only inadequate to correctly deal with insufficient local

Aggregate ketamine doses >200 mg is associated with prolonged emergence. **Do not exceed 200 mg ketamine or give ketamine in the last 20 minutes** of the case or use ketamine in cases less than 20 minutes. Spontaneous ventilation is a prized safety feature of "Goldilocks" anesthesia. **Do not introduce an MH trigger like SCH to treat laryngospasm.** Because of the

Do not mix propofol and ketamine. Titrate separately to define goals of adequate hypnosis and midbrain NMDA

amine hallucinations. **Do not give ketamine if BIS > 75 or EMG is not at baseline.**

tion to define midbrain NMDA receptor saturation (**Table 5**).

analgesia but also increases the probability of PONV.

**propofol with ketamine.**

boluses.

saturation.

Do not give ketamine before propofol.

Do not fail to provide adequate local analgesia.

Do not give opioids in lieu of adequate local analgesia. Do not give ketamine in lieu of adequate local analgesia. Do not exceed an aggregate ketamine dose >200 mg.

Do not paralyze instead of using lidocaine to break laryngospasm. Do not use succinylcholine instead of lidocaine to treat laryngospasm.

Do not give ketamine in the last 20 minutes of a case or for cases <20 minutes duration.

Do not give ketamine at BIS > 75.

**Table 5.** Pitfalls to avoid.

Do not bolus propofol for induction. Incrementally induce.

The surgeon should inject as much of the proposed surgical field(s) with the initial ketamine dose whenever possible. Review of 1000 patient records demonstrated 80% were performed with one or two 50 mg ketamine doses. **Aggregate ketamine doses greater than 200 mg were associated with prolonged emergence**. Many surgeons are concerned that the lidocaine or epinephrine effect will not last if a lengthy procedure is contemplated. Long experience with Klein's ultradilute solution [21] has shown that concern is unwarranted even in 6-hour cases. Ketamine is to facilitate a painless injection of **'virgin' surgical fields** and is not necessary for reinjections when needed.
