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to 0.3%). This way, I know propofol is the only remaining agent sedat-
ing the patient.
• At the very end, reverse the partial paralysis. The remaining propo-
fol is metabolized, resulting in a gentle, peaceful emergence, similar to
that of a sedation case.
The technique is most easily mastered in non-obese, ASA I and II
patients, and with surgeons who are reliable in their pace.
Bookending can then be tailored, based on BMI and/or case duration
— that is, transitioning earlier to allow more complete elimination of
gas. In general, the parameters to consider when transitioning include
the timing of the transition, the dose and frequency of propofol bolus-
es, the oxygen flow rate used to eliminate gas, and establishing a
reversible depth of paralysis that allows for rapid reversal at the very
end. Intuitively, it may seem preferable to avoid paralysis and mechan-
ical ventilation until the end, but it's the best way to effectively drive
out the anesthetic gas.
Augmenting the technique
I also incorporate other practices to help minimize PONV. To manage
pain, I give narcotics mostly toward the beginning of a case, and use
ketolorac when transitioning. In longer cases and/or those with
greater patient exposure, I use a forced-air warmer to maintain nor-
mothermia. You should also optimize fluid balance and avoid nitrous
oxide, especially in long cases. OSM
Dr. Reines (mreines@mac.com) is an anesthesiologist at Daydream Anesthesiology in Newport Beach,
Calif. He serves as clinical anesthesia director at the Skin Cancer and Reconstructive Surgery Center in
Newport Beach, Calif.
