ABCs of Anesthesia
This letter is in reference to Dr. Alan Marco's article in the January 2002 issue of Outpatient Surgery.

Over the past ten years, using propofol ketamine anesthesia, I have had a 0.5 percent PONV rate in a population of nearly 3000 patients who experienced a previous 35 percent PONV rate without the use of antiemetics. My method works well for hernial surgery, arthroscopy, gynecologic laparoscopy, lithotripsy, and all cosmetic surgeries, ranging from abdominoplasty to sub-pectoral breast augmentation, to facelifts. Time is not a limiting factor, either.

Regarding premptive anelgesia, blocking the mu receptors with opiods will not block the sensory input of the local anesthesia injection. In a decade of office-based experience, I have not had a single admission for either PONV or uncontrolled post-op pain. Opioids are scrupulously avoided and the result is an essentially zero PONV outcome.

Finally, in regard to the BIS monitor, I strongly believe that is a valuable tool for the experienced anesthesia provider as well as less experienced providers. While it takes a learning curve of 20-50 cases to master it, the BIS gives the experienced provider information available from no other source. Trending the EMG as a secondary trace gives the provider a real-time predictor of patient movement. Also, by reducing unnecessary drug usage, it speeds the case through the facility. More cases means more income!

Barry L. Friedberg, MD
Chief Clinical Instructor in Anesthesia
University of Southern California
Los Angeles, CA

Infection Prevention
In your February 2002 Infection Prevention column, Dan Mayworm misleads the reader by referencing invalid research done by Karen Leonas at the University of Georgia. Referring to this paper by Leonas without the respective letters to the AJIC editor following its publication paints not only an inaccurate picture about the barrier properties of reusable products but a significantly biased one as well.

The Leonas paper had serious flaws in the scientific approach as well as the conclusions drawn from the data. The study utilized an inappropriate and obsolete method of testing and reached conclusions that were dramatically at odds with those of many other studies.

During liquid-based microbial challenge testing, many variables can affect the outcome of the test. Depending on the interaction between the liquid and the test material and the pressure applied to the liquid, there will be a limit to the sensitivity of the test for finding penetration pathways for the challenge liquid and microbe.

There has been little concensus over testing methods. The Food and Drug Admininstration and the AAMI are currently taking several steps to address the need for clarification regarding barrier performance. Hopefully, their work will better explain to end-users the important issues related to barrier properties of surgical gowns, drapes, and other items of use in healthcare facilities.

Peter L. Brown
Associate
W. L. Gore