As a 40-year practicing, board-certified anesthesiologist, I am concerned much of the current opioid crisis revolves around how anesthesia is routinely administered.

"More than 75% of heroin overdoses begin with prescription drugs", said Dr. Toby Cosgrove, Cleveland Clinic CEO. Many patients get prescription opioids for relief of postoperative pain. Opioid Free Anesthesia (OFA) not only uses no opioids during surgery but also radically reduces the need for them after surgery.

Many people originally become addicted to opioids after taking them for postoperative pain relief. By reducing or even eliminating the need for opioid medications after surgery, an entire population of addicts may be prevented.

Routine opioid use began with premedication to minimize secretions and induction excitement [1]. If opioids are so effective mitigating postoperative pain, why does postoperative pain management remain an issue? [2,3] Opioids are for anesthesiologists that don't know how to preemptively saturate infra-tentorial NMDA receptors to block pain from the first stroke of the scalpel.

As long as one violates the integument, all surgery (i.e. thoracic, neuro, ortho, ENT facial or other cosmetic) is the same information for the sedated/anesthetized brain. The worst possible message for the surgery patient's brain is the knowledge of the penetration (invasion) of the protected world of self. Although other pain receptors exist within the body, no other cortical signal is more critical to postoperative outcomes than the 'invasion' of self.

A surgeon's scalpel is no different to the medicated brain than a mugger's knife. The use of pre-incision subcutaneous local anesthesia as well as the pre-closure splash of bupivacaine prolongs the 'deception' or the brain's ability to perceive the violation of the skin.

Prior to the advent of direct cortical monitors, anesthesiologists relied on the absence of heart rate (HR) and blood pressure (BP) changes at incision to determine adequate anesthesia was achieved. The ASA Awareness study revealed half of the patients who experienced awareness with recall under anesthesia had no HR or BP changes with which to alert the anesthesiologist [4].

With the perspective of direct brain monitoring information, it is now understood that HR & BP changes most accurately reflect brain stem signs and are notoriously unreliable guides to cortical responses. However, pain and the awareness of consciousness are processed at higher, cortical levels [5].

In 1996, the Food & Drug Administration (FDA) approved the bispectral (BIS) index to directly measure the cortical anesthetic response to hypnotic agents like propofol. The BIS monitor has been validated in more than 3,500 studies and is found in most hospitals and ambulatory centers where anesthesia for major surgery is given. Other brain monitors like Entropy are also available but there is no literature claiming superiority to the BIS.

The BIS brain monitor generates a number between 0-100 from a two lead EEG forehead sensor. The lower the number, the more hypnotized is the patient (Table 1) [6].

Table 1: BIS and levels of sedation/anesthesia [9].

BIS below 40 is considered over medicated. Use of the sensor and monitor is cost effective [7]. Neither cost nor difficulty reading the monitor should impede its regular use for major surgery under anesthesia, the goal of the nonprofit Goldilocks Anesthesia Foundation (www.goldilocksfoundation.org).

Free-standing BIS A-2000 and VISTA units have software that enables the selection of the electromyogram (EMG) as a secondary trend. EMG is to the facial frontalis muscle what EKG is to the cardiac muscle; i.e. a directly measured real time signal. EMG spikes persist in the presence of neuromuscular blocking agents as well as Botox. EMG spikes signal incipient arousal [8,9]. BIS without concomitant EMG trending is like trying to drive a car with only rearview mirror information.

Postulates

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1^st Postulate: Without nocioceptive arousal the cortex cannot process pain.

2^nd Postulate: Opioids fail to block cortical input.

3^rd Postulate: Measurement is the basis for scientific practice.

4^th Postulate: EMG spikes absence with skin violation is prima facie evidence of infra-tentorial receptor saturation.

5^th Postulate: Infra-tentorial NMDA receptor saturation with 50 mg IV ketamine 2-5minutes pre-incision blocks cortical input.

6^th Postulate: NMDA receptor saturation creates opioid free, preemptive analgesia.

On March 26, 1992, 26 years of opioid free anesthesia for office-based elective cosmetic surgery anesthesia was initiated using propofol ketamine (PK) sedation; i.e. hypnosis first, then dissociation [10]. During the first 15 years of a 40-year private practice, anesthesia career, never once did patients' need for postoperative opioid pain therapy occur to this author.

By the spring of 1993, 50 consecutive PK Apfel-defined postoperative nausea & vomiting (PONV) high risk patients (i.e. non-smoking, females, history of PONV or motion sickness, having emetogenic surgery) [11] emerge entirely devoid of opioid pain relief need. Also observed was the virtual absence of PONV without anti-emetic drugs. PONV is patients' #1 outcome to avoid after surgery [12]. Only after adding the real-time BIS brain monitor was the PK paradigm numerically reproducible.

The lack of need for postoperative opioid pain relief led this author to conclude patients had pain upon awakening because they were having pain during surgery! This was an astonishing insight considering the cardinal function of anesthesia is the prevention of pain during surgery.

Prior to ketamine, patients were premedicated with 0.2 mg glycopyrrolate then had propofol incrementally titrated to 60 < BIS < 75 with baseline EMG [13]. Ketamine 50 mg independent of adult body weight was administered 2-5 minutes pre-incision. Pre-incision lidocaine was infiltrated. Prior to closure, bupivacaine (not to exceed a total of 125 mg or 50 ml of 0.25%) was splashed into the wound.

Dexamethasone was not given for the first 1,264 patients when the lowest published PONV rate was published in an Apfel-defined high risk patient population without anti-emetic administration [14]. Beginning in May 2009, dexamethasone 10 mg IV was given at induction with no change in PONV incidence.

Validation of Postulates

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From 1998 through 2018, over 4,000 painful outpatient patient surgeries (i.e. subpectoral breast augmentation and classical abdominoplasty) were performed under BIS/EMG monitored, propofol hypnosis using preemptive ketamine (i.e. midbrain NMDA receptor saturation), followed by injection of subcutaneous local anesthesia without postoperative opioid rescue or a single hospital admission for pain. Patients rarely used postoperative opioids. No reports of opioid addiction were observed [15].

Preemptive ketamine prevents pain during surgery with dramatic reductions and, often elimination, of the need for opioids after surgery. No hospitalizations for postoperative pain management or PONV occurred during 20 years of opioid free anesthesia (OFA) for more than 4,000 patients.

Preemptive ketamine tricks the brain by denying it the information the body has been 'invaded' by the surgeon. During the magic interval between surgical intrusion and the 'discovery' of intrusion, healing takes place. That interval permits a degree of healing with a dramatic reduction, not infrequently the elimination, of opioid requirements for pain.

Opioid free anesthesia (OFA) patients look like surgery never even happened! OFA embodies Friedberg's Triad (Table 2). Real time brain monitoring should be the standard of care for major surgery under anesthesia.

Table 2: Friedberg's Triad.

Disclaimer

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Neither Dr. Friedberg nor the nonprofit Goldilocks Anesthesia Foundation receive BIS maker financial support.

References

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13. Propofol Induction Using BIS Monitor without Instrumenting Airway.
14. Friedberg BL: Propofol-ketamine technique, dissociative anesthesia for office surgery: a five-year review of 1,264 cases. AesthPlast Surg 1999;23:70-74.
15. Friedberg BL: Can Friedberg's Triad solve persistent anesthesia problems? Over-Medication, Pain Management, Postoperative Nausea and Vomiting. PlastReconstr Surg Global Open 2017;5:e1727-1734.