California Society of Anesthesiologists Bulletin 62-4 - (Page 34)
THE VOICE OF EXPERIENCE
Bookending Propofol -
a Technique to Avoid PONV
By Michael Reines, MD
P
ostoperative nausea and vomiting (PONV) are significant side effects
that contribute to patient dissatisfaction in outpatient surgery. As a result,
anesthesiologists have tried a variety of drug combinations and strategies to
minimize the incidence and severity of PONV. I have personally had success in
achieving this using a technique I call "bookending" propofol.
Propofol has antiemetic properties,1 and I believe the ultimate outpatient
anesthetic takes advantage of this. Several studies show that propofol is superior
to volatile agents in avoiding PONV.2-4 Many anesthesiologists induce anesthesia
with propofol, then switch to a potent volatile agent for maintenance. Others
administer a continuous infusion of propofol for the duration of anesthesia. A
Dr. Reines graduated from
Columbia University with a
degree in mechanical engineering
third alternative, the one I call "bookending," starts with a propofol induction,
continues with a potent inhalational anesthetic, and then switches back to
propofol for the final 15 to 30 minutes of the procedure.
before attending medical school
at Wayne State University in
In 1996, a study by Gan, et al., published in Anesthesiology looked at the efficacy
Detroit. He did his anesthesia
of two regimens of propofol administration. One group received a bookending
residency at Northwestern
technique: propofol for induction, isoflurane for maintenance, and then propofol
University, and then worked for
again at the end when the inhalational agent was turned off. The transition
12 years as a solo practitioner
in rural Michigan, covering all
subspecialties. He now practices
occurred 30 minutes prior to closure, and propofol was infused to the end of
the surgery. A second group received a bolus of propofol for induction and a
outpatient anesthesiology in
continuous infusion for maintenance until the end of the case. The authors found
Orange County.
a significantly reduced incidence of PONV in the patients receiving propofol from
beginning to end.
I believe that a shortcoming of this study was not measuring the elimination of
isoflurane. Without that information, the presence of residual inhalational agent
could confound the data, which I believe led to the authors' mistaken conclusion
that bookending propofol is less effective in minimizing PONV.
34
| CSA Bulletin
Table of Contents for the Digital Edition of California Society of Anesthesiologists Bulletin 62-4
Airliner Crashes and Patient Handoffs — Is There a Connection?
It Is a New Day
LPAD Gears Up for a New Year
Full House? Playing Political Poker ‘Under the Dome’
CSA FALL SEMINAR 2013: ANOTHER HAWAIIAN SUCCESS
The ASA Annual Meeting
UPCOMING CSA ANESTHESIA SEMINARS
Is ‘HAL’ Coming to a GI Suite Near You?
Bookending Propofol — A Technique to Avoid PONV
Process and Outcome: Lessons from Fountain Valley
An Educational Gift from the Internet
A Major Challenge to Your Practice from Sacramento
Propofol Dreams: Of Nightmares and Déjà Vu?
NEW MEMBERS
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