• Mitch Keamy Photo Mitch Keamy is an anesthesiologist in Las Vegas Nevada Andy Kofke Photo Andy Kofke is a Professor of Neuro-anesthesiology and Critical Care at the University of Pennslvania Mike O'Connor Mike O'Connor is Professor of Anesthesiology and Critical Care at the University of Chicago Rob Dean Photo Rob Dean is a cardiac anesthesiologist in Grand Rapids Michigan, with extensive experience in O.R. administration.

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I guess since you "routinely" use the BIS monitor, the increase in patient questions (fear) promented by the news media and movie shouldn't be a problem. Well, other than the increase in time spent to calm and educate the patient/family.

Very nice post!


where have you guys been??


Good post Andy! The comment about excessive depth of anaesthesia and increased mortality is interesting. It raises the possibility of an inherent toxicity of general anaesthetic agents. As a followup to the B-aware study (Lancet 2004: 363:1757-1763) we are reviewing the survival at one year of those patients and relating it to their BIS readings.

Hansel de Sousa

You can't have it both ways with BIS. You modify your existing clinical skills by using BIS to either avoid anesthetic overdose and risk greater awareness, or to avoid awareness by increasing anesthetic depth and increasing the risk of overdose. Using BIS has both increased awareness and killed from overdose.

Barry L. Friedberg, M.D.

Since December 1997, I have routinely titrated propofol hypnosis with a BIS Monitor to 60-75, a range compatible with moderate to deep sedation for my office based elective cosmetic surgery patients, resulting in significant propofol cost savings in addition to rapid, clear-headed recoveries.(1-3)

Anesthesia awareness does exist and should be reduced. Routinely overdosing patients for fear of under-dosing is a ubiquitous practice which may result in increased one year mortality (4) and well as elevated C-reactive protein markers (5) both of which may augur postoperative cognitive dysfunction (POCD). POCD (the `forest`) is a far greater issue than that of anesthesia awareness (the `trees`). Let's not miss the forest for staring at the trees.

My BIS monitored propofol ketamine sedation or `Goldilocks` anesthesia is that which is neither too much, nor too little, but just right.

Anesthesia awareness has occurred in none of my more than 2,000 BIS monitored, albeit low awareness risk, patients since December 1997.

The brain is the target organ of the anesthesiologist's drugs. Why not measure it?

Barry L Friedberg, MD
Cosmetic Surgery Anesthesia -
Corona del Mar, CA 92625
[email protected]


1. Friedberg BL, Sigl JC: Bispectral (BIS) index monitoring decreases propofol usage in propofol-ketamine office based anesthesia Anesth Analg 1999;88:S54.
2. Friedberg BL, Sigl JC: Clonidine premedication decreases propofol consumption during bispectral (BIS) index monitored propofol-ketamine technique for office based surgery. Dermatol Surg 2000;26:848-852.
3. Friedberg BL: Propofol ketamine with bispectral (BIS) index monitoring chapter in Friedberg BL (ed): Anesthesia in Cosmetic Surgery. Cambridge University Press, New York 2007;1-14.
4. Monk TG, Saini V, Weldon BC, et al.: Anesthetic management and one-year mortality after non-cardiac surgery. Anesth Analg 2005;100:4-10.
5. Kerssens C, Sebel P: Relationship between Hypnotic Depth and Post-Operative C-reactive Protein Levels. Anesthesiol 2006;105:A578.
red dotted rule

Disclaimer: Dr. Friedberg is not employed by Aspect Medical Systems, makers of the BIS monitor. He is neither a stockholder nor a paid consultant. His opinions are solely based on the 11 years of his experience with BIS monitoring.

richard fuller

Hi all,

Great site love the look and feel of the place. We have a new site about blood monitoring so please give us a quick look and tell us what you think.


I saw that you talked a little about Over Dosing. Recently we found out that the great Michael Jackson died from overdosing! There is more information on it here Michael Jackson Diprivan


very nice your blog

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