Propofol-Ketamine Technique
Happy Drugs for Happy Surgery
In spite of critics who point to its club drug reputation and its relatively limited history as an operative anesthetic on human patients, Barry Friedberg, MD, is convinced that ketamine - known as Special K on the street - is the safest pain inhibitor for patients to receive during surgery.

How to Administer PK 1. For pre-emptive analgesia, give patient antihypertensive clonidine (Catapres) 0.2 mg and NSAID rofecoxib (Vioxx) 50 mg PO. 2. To reduce salivary secretions from ketamine, inject 0.2 mg glycopyrrolate (Robinul) before induction with propofol. 3. Obtain baseline EKG, pulse oximetry and BIS values. 4. Gradually introduce (no bolus dose) propofol 2-5 minutes prior to the procedure. Two reasons for the gradual administration: to preserve spontaneous ventilation and to provide a stable level of propofol in the brain before the ketamine is injected. 5. Once you've observed loss of both lid reflex and verbal response, administer 50 mg ketamine bolus and wait 2-3 minutes before injecting the local analgesic. Without the BIS monitor, administer ketamine after loss of both lid reflex and verbal response. With BIS, wait until a level of 70-75 before giving the ketamine. "Think of propofol as the martini," says Dr. Friedberg, "and ketamine as the olive."

"Ketamine has a virtually spotless safety record when administered properly by clinicians," says the 53-year-old Corona del Mar, Calif.-based anesthesiologist who pioneered the propofol-ketamine (PK) anesthesia technique for office-based cosmetic surgery. "We can't say the same for opioids. Opioids depress the patient's drive to breathe as well as the laryngeal or life-protecting reflexes. Not surprisingly, respiratory complications are the number-one cause of anesthetic mishaps in the office setting. Ketamine, on the other hand, supports the breathing drive and increases the life-preserving reflexes."

Ketamine has been used clinically, primarily as a veterinary anesthetic, for 38 years, says Dr. Friedberg, who began using the drug in 1992, because he was going to work in an outpatient facility that had recently experienced the ultimate bad outcome. An otherwise healthy 34-year-old woman died during a routine cosmetic breast procedure using IV sedation with opioids.

Ketamine has been popular in the club scene since the 1980s because of its PCP- and LSD-like hallucinogenic effects. Dr. Friedberg advocates its use in most outpatient surgeries, not just for cosmetic procedures. He says the rate of post operative nausea and vomiting with the generally high-PONV risk group of patients with whom he works is a mere 0.5 percent and the outcome has been consistently reproduced by other clinicians using the same combination of ketamine and propofol. Plus, he says, "you can't have PONV after a patient has had a facelift or a tummy tuck."

Hand Hygiene: Alcohol Gels Are Better Than Washing
CDC Backs Hand Rubs Over Soap and Water
The government issued guidelines urging doctors and nurses to abandon the ritual of washing their hands with soap and water between patients and instead rub on fast-drying alcohol gels to kill more germs.

The goal, the government said, was to reduce the spread of viruses and bacteria that infect an estimated 2 million hospital patients in the United States each year and kill about 90,000. Soap and water have been the standard for generations. But washing up properly between each patient can take a full minute and is often skipped to save time.

"These products are more accessible than most sinks and many physicians as well as staff are already using them," says Greg Carter, RN, manager of infection control and reprocessing at Kettering Medical Center in Kettering, Ohio.

While the alcohol-based gels and solutions kill more microbes, the main advantage is that they are easier to use. With vials clipped to their uniforms, nurses can quickly swish their hands while on the move without stopping at a sink. Using the gels involves squirting a dime-size dollop on one palm and then rubbing the hands. The alcohol dries in seconds without a towel and is so easy to use that many are saying that it is almost indefensible now not to clean your hands.

"We will end up with more people doing the right thing and cleaning their hands," says Dr. Julie Gerberding, director of the Centers for Disease Control and Prevention.

A few important points:

• The new guidelines pertain only to hand washing, not to surgical scrubs or patient preps. Each is considered a discrete area of asepsis.
• The new guidelines apply only to hospitals and clinics.
• The alcohol gels are intended only to kill germs, not to remove visible dirt. You are still expected to wash up if you get soiled hands.
• Surgeons have the choice of using the gels in combination with soap and water or sticking with antimicrobial soap.

FDA considers waterless instant sanitizers safe and effective but has not yet stated that there is conclusive enough evidence to declare them more effective than soap and water for hand washing.

CMS Issues Final Outpatient Rule for 2003
Cataract/IOL Reimbursement to Increase by $104
The Centers for Medicare