Dear Dr. Friedberg:

I just finished your wonderful book Anesthesia for Cosmetic Surgery. What a revelation. I have been using benzodiazepines and ketamine for 30 years for nearly all of my elective aesthetic plastic surgery cases and for many hand and trauma cases. During this time, I have never had a deep vein thrombosis, a pulmonary embolism, a positive pressure, a pneumothorax, a negative pressure pulmonary edema, a flash pulmonary edema, a chipped tooth, an injured vocal cord, a fire or explosion in the operating room or damage to the trachea of a patient, intractable postoperative nausea and vomiting, an awake but paralyzed surgical patient, aspiration, or litigation involving anesthesia. Recent teaching courses and patient safety continuing medical education (CMA) requirements in plastic surgery have focused on the prevention of deep vein thrombosis and postoperative nausea and vomiting. These are complications not of minimally invasive surgery but of maximally invasive general anesthesia.

When I have suggested to my colleagues that all cosmetic surgery can be performed safely, simply with IV sedation, they are reluctant to try because they are accustomed to having an anesthesiologist monitor the level of sedation and are concerned that clinical impressions are not adequate. Your book that clearly describes the use of propofol and the BIS monitor solves their dilemma. Studies have shown that incidents of deep vein thrombosis, subsequent pulmonary edema increases with every hour of general anesthesia. Universal acceptance of your principles of intravenous sedation for minimally invasive anesthesia for minimally invasive surgeries can save thousands of innocent lives each year.

Robert A. Ersek, M.D., F.A.C.S.

Hi Barry:

Thank you for the autographed copy of your book. It was very thoughtful of you and it will have a special place in my library.

You have made an important contribution to the clinical practice of anesthesiology and this publication should further its use among our colleagues.

Keep up the good work. I am proud of you.

C. Philip Larson, Jr., MD
Chaiman of the Deparment of Anesthesia at
Stanford University during Doctor Friedberg's
training from 1975 to 1977.

"Dr. Barry Friedberg - Cosmetic Surgery Anesthesia - Propofol Ketamine is my primary technique for almost all office based anesthesia cases including facelifts, eyelifts, laser skin resurfacing,
liposuction, rhinoplasty(closed), and frankly any other case that is superficial... Another advantage of this technique is the low incidence of post operative nausea and vomiting (PONV).

Marshall M. Garland, MD
Assistant Professor of Anesthesiology
NYU Medical Center
New York, NY

"Dr. Friedberg's long-standing vision, innovation, and tireless devotion to the practice of cosmetic surgery anesthesia is efficient and thoughtful, while providing for a practical, outcomes-directed approach to office-based
cosmetic surgery anesthesia. The sticking point for many patients is the post-surgical experience of nausea and vomiting (PONV). Dr. Friedberg's PK
technique, which is applicable to a variety of elective cosmetic surgical procedures, reduces this uncomfortable byproduct of an otherwise
positive surgical outcome. As more consumers know about this option,
elective cosmetic procedures may be more widely and easily embraced."

David Mayer, MD
Board Certified Anesthesiologist
President, Esurg Corporation
Medical and Pharmaceutical Supply Company
Seattle, WA
dmayer1@uic.edu
www.esurg.com

"Well indeed, I had to see it to believe it, my last 15 cases where I have used your technique, no narcotics, and they have done well! It is also so enjoyable to see them awake and be so happy. Not even a hint of nausea and vomiting. Fantastic."

Frank Kunkel, MD
Private Practice Anesthesiologist
Pittsburgh, PA
Fak9717@hotmail.com

"Dr. Friedberg's PK technique has worked wonders for my patients. They awaken from anesthesia with a very happy affect, frequently reporting an enjoyable experience! This is what distinguishes PK from other anesthesia techniques. Furthermore, the paucity of nausea, hallucinations, or delayed discharge has made the technique an invaluable component of my armamentum. Dr. Friedberg deserves all the accolades for enlightening our company. His zeal to educate colleagues and patients is unmatched."

Marc Koch, MD, MBA
President and CEO
Somnia, Inc.
New Rochelle, NY
www.somniaanesthesiaservices.com

Charles E. Laurito, MD
Professor of Anesthesiology
and of Anatomy and Cell Biology
Director, Pain Management Program
Chicago, IL
President, Society for Office Based Anesthesia

Dear Barry,

I am deeply impressed with your carefully researched letter to Dr. Gupta. Instead of obfuscating ketamine's merits as some "experts" have in recent past, you have published in peer reviewed journals and thereby have provided us with an empirical basis to move forward with exciting new applications for this old drug. In addition, the presentation of your research before state anesthesiology societies, such as ours in Florida, has been a great benefit to our profession. I hope that people like Dr. Gupta will not become a member of that crowd who fail to understand that clinical science can and has been advanced by people like you.

The tide of history is at times slow for us humans human beings, but it moves nonetheless. More and more anesthesiologists are growing uncomfortable with the view about your work expressed by people like Dr. Gupta.

Once again, I commend you for your important contribution consonant with the highest principles of our profession.

Anthony Kirkpatrick, M.D., Ph.D.
akirkpat@hsc.usf.edu

"Yesterday I anaesthetized a 54 year old for mastectomy and tissue expander. Always sick after anesthesia, she was anaesthetized about 2 weeks ago whilst I was on holiday, and the anesthetist made bold efforts to prevent the heaving by adding in metoclopramide, and ondansetron during the anesthetic. She woke up and immediately felt sick. She was administered cyclizine (an antihistamine type anti-emetic) and immediately developed a kind of locked in syndrome. So not only did she continue to feel sick, but she had the terrifying experience of not being able to move.

Yesterday she was extremely apprehensive about a further anesthetic. I gave her the PK "its anesthesia Jim, but not as we know it". She woke up, pain free, nausea free and laughing. Many thanks again."

Chris G. Pollock MB ChB
madgas@poloks2.karoo.co.uk
Consultant in Anaesthesia and Pain Medicine
Castlehill Hospital
Hull , UK

"Dr. Barry Friedberg has revolutionized my anesthesia service. We have performed over 100 abdominoplasties under propofol ketamine anesthesia. The patients are extremely happy with his anesthesia. They feel great upon awakening and have almost no nausea or vomiting. Wow, what a difference it makes!!!"

Nikolas V. Chugay, D.O.
Internationally recognized aesthetic plastic surgeon
Developer of buttock, bicep and tricep augmentation
www.drchugay.com

"Barry Friedberg invented and popularized our techniques and does it in a more sophisticated fashion. The following is especially modified for liposuction.....PK technique: Safe, very little respiratory depression and NO post operative nausea or vomiting. Propofol (soporific only; short acting, anti-nausea) drip to sedate, then 50 mg of ketamine (dissociative anesthetic: salivation, great but brief analgesia, blood pressure elevation, short acting) slow IV push (watch for respiratory depression carefully for a few minutes) and two minutes later, pump in tumescent as rapidly as possible with your peristaltic pump. This is a very small dose of ketamine, and with this dose, the dysphoria that the anesthesiologists object to virtually doesn’t occur. Robinul (drying agent) 0.2 mg (1 cc) given IV at the start of the case; usually prevents salivation and occasional respiratory problems that occur occasionally with Ketamine."

Robert Yoho, MD
"Yoho Method” liposuction anesthesia technique ABCS board certified in cosmetic surgery a ABMS board certified in emergency medicine
www.dryoho.com

"Friedberg is a respected anesthesiologist, frequently cited for spearheading the innovation of PK to tame the negative effects of cosmetic surgery anesthesia. His deep sense of commitment to patients and the surgeons he works with is globally known, and his selfless efforts to educate both populations is a tribute to the field of medicine, surgery, and anesthesia."

Nicanor G. Isse, MD
Internationally recognized plastic surgeon
Specialist in Scarless and Minimal Incision Surgery
Director of Isse Institute for Cosmetic Surgery
Los Angeles, CA
drisse@iconoplasty.com
www.iconoplasty.com

Subject: CRNA's ask, too

Hi! I am a CRNA in Louisiana interested in learning your PK technique. I am employed by 5 plastic surgeons and 2 of which trained at Stanford (these both state that propofol was the main anesthetic used there). I am willing to learn, but they have a hard time realizing that the patients may move at times. I did a blepharoplasty that went well with a propofol drip and the patient was real happy. Of course, I trained 23 years ago and was always told that ketamine gives the nightmares. At what BIS reading do you find that it is ok to give the ketamine? Does this last for the duration of the local if the doc takes 5-6 hours? Let me know I will download your articles at work and read them.

Thanks, Leslie

---------------------------------

Leslie,

Thank you very much for your interest in PK.

Doing PK MAC* is much more an attitude than an aptitude. You already possess 1,000X the talent to do PK. It's very simple and it works. Picture yourself removed from the 'analgesia' business and posture yourself as a propofol hypnotist (99%). The dissociative dose of ketamine(1%) creates the window of opportunity in which to inject the local without hurting the patient. Good local is the key.

Hypnosis first, then dissociation is the other key. Without the BIS, hypnosis is loss of lid reflex and loss of verbal response before dosing with the ketamine. With the BIS, it's 70-75 before ketamine. Also, when the patient moves at BIS = 60-70, they must realize more lidocaine not propofol is the correct response. All of my surgeons are now trained to ask what the BIS is when the patient moves.

Ketamine is not a fentanyl substitute. Once the local is injected there is no reason to persist in giving more ketamine. I logged 2,680 PK cases in ten years. Surveying my last 500 cases, 40% were done with a single 50 mg bolus of ketamine, 40% were done with two 50 mg boluses, and only 20% required additional ketamine. Do not exceed an aggregate of 200 mg ketamine in any case and absolutely none in the last 20 min....and does this last for the duration of the local if the doc takes 5-6 hours?

The length of case is irrelevant as is the patient weight. The small portion of the midbrain and spinal cord containing the NMDA receptors does not vary appreciably in adults, so 50 mg works pretty darn well (95-98%) of the time. I cut back to 25 for Asian born Asian patients. Also, 25 mg will get you about an 80% response rate in gringos. Too tedious for me.

As a point of curiosity, did your surgeons express an interest in PK or did you suggest it to them? I am curious because I want to know what the force for change in your interest was? Did you see one of my ads celebrating 10 years of better anesthesia?

The web site was created to inform patients about PONV free anesthesia in PK and to ask for it!

Please keep me posted on your experiences if you can. I am always interested in feedback from my 'disciples.'

Most of my 5 articles are on the web site under 'Published Articles.'

Yours for better ( & reproducible) outcomes,

Barry L. Friedberg, M.D.

---------------------------------

P.S.
Look for 2003 International Anesthesiology Clinics Vols I & III for my two chapters on PK including 'the cookbook.' I'll be at the Lippincott booth at 2003 IARS, SAMBA, ASA, & PGA to autograph copies. Hopefully, one will be for you. I don't receive royalties or any other form of remuneration. Just trying to promote PK. Tell your friends. Tell your surgeons that one of my main clients is Nicanor Isse & watch their eyes get big with recognition. Isse pioneered endoscopic browlift in '92, ironically the same year I pioneered PK. Took us minimalists a while to find each other. :-) He does minimally invasive cosmetic surgery & I do minimally invasive anesthesia^®.

*PK MAC is derived from Vinnik's diazepam ketamine technique, published 1981 in PRS. PK TIVA wherein the two are mixed together is derived from Guit 1991 Anaesthesia. Mixing involves two hazards - 1) one may not achieve the all-or-nothing threshold of dissociative effect (i.e. patient does not move for local injection) & 2) more likely to exceed the 200 mg aggregate dose of ketamine producing an unsatisfactory emergence. 

Dear Barry,

It was a great pleasure meeting you in California recently, on the occasion of the endoscopic seminar. Your anesthesia techniques are superb and your chapter in the anesthesia textbook for head and neck, as well as oral surgery is very clear and most informative.

Again, thank you for everything. I learned a great deal talking to you and watching you provide anesthesia.

Very sincerely,

F. Don Parsa, M.D., F.A.C.S
Professor of Surgery (Plastic)
University of Hawaii
The John A. Burns School of Medicine
Chief of Plastic Surgery Division – The Queen’s Medical Center
 

Barry,

Just a quick line to let you know that the residents, and other faculty, have been impressed with PK. Recently, I used PK for an ASA IV patient. He was a 60+ year old w/IDDM and just several days "out" from a severe acute AWMI. His EF was < 20%. The patient required an emergent BKA.

I did the case, with a resident, with a combined anterior sciatic block and femoral block. PK worked just fine. The residents (anesthesia and surgical) were amazed. So was the vascular surgeon.

In addition, PK worked extremely well, as a supplement, to an axillary block for a renal failure patient. The patient needed the usual AV graft for dialysis access. He was awake and ready for d/c almost as soon as the "stuff" was shut off.

Glen Atlas, M.D., M.Sc.
hga@earthlink.net
Associate Professor of Anesthesia
New Jersey College of Medicine and Dentistry