Ativan IVP vs Propofol gtt

[General E. Speaking, RN]

Had a patient on Propofol gtt (and Fentanyl gtt @75mcg/hr). S/P laparotomy. Possible aspiration- he was on a vent (PSV). He was lethargic but calm and arousable and would follow commands. Pulmonologist calls and I update on status. He ordered me to cut back on Fentanyl to 25mcg/hr and wean off Propofol in anticipation of extubating the next morning.

Once I had stopped the propofol pt became increasingly more agitated. He nodded "yes" to are you in pain so I called the doc back and got him to up the Fentanyl to 50 mcg/hr.

Pt still not settled. HR shoots up from 80s to 150s, A-line b/p goes from SBP of 100-110s and DBP of 60-70s to 200s over 100s. Called doc back and updated. He orders ativan 1-2mg O2hrs prn. I asked if we could turn the propofol back on but he refused stating it would delay extubation. In the mean time, I gave lopressor IV for BP. The 2mg ativan didn't touch him. He con't to be more restless with high bp. Gave vasotec IV. Updated on RR in the 40s wet lungs and 6 liters+. No orders for that.

Called the PCP (instead of pulmonary doc) updated and he gave me and order for labatolol. I asked him about restarting the propofol gtt but he refused to 'over ride" the pulmonary doc orders. His lungs were sounding wet and I updated him that he was 6liters + on I&O. 40mg lasix ordered and given. he dumped about 900 ml after that.

I called the pulmonary doc back. VS still out of whack and climbing. We put him on A/C. By this time my heart rate is up and I guess I was talking fast. He tells me to "calm down" and to extubate the patient. "Are you kidding me?" was the word vomit that came out. I told him "no way". He ordered Geodon IM and says I can give the Ativan Q1 hr.

It was shift change by then and already had another call into him but he wasn't calling back. Geodon given. When I finally left after catching up on my charting, he was still bucking the vent and not following commands. BP did finally come down some.

Here's my question: Why wouldn't he want to continue the propofol since it is so short acting. Seems to me that it would be better than pushing 2mg of Ativan Q1 hour thru out the night. Wouldnt it have been better to keep the propofol infusing than wait for who knows how long for the ativan to wear off.

Thanks

[wtbcrna, MSN, DNP, CRNA]

Dex is not an analgesic and the patient would still need some sort of analgesic support.

Precedex does have analgesic properties and can/is used as the sole sedating/analgesic quite often.

http://anesthesia.ucsf.edu/neuroanesthesia/residents/respdf/Dexmedetomidine_neurosurgery.pdf

[meandragonbrett]

Precedex does have analgesic properties and can/is used as the sole sedating/analgesic quite often.

http://anesthesia.ucsf.edu/neuroanesthesia/residents/respdf/Dexmedetomidine_neurosurgery.pdf

Excellent! Thanks for the article. I was unable to find anything while at work regarding it's analgesic properties.

[suanna]

Propofol is a severe respiratory depressant, Ativan can do the same but is dose dependent, 1-2 mg Q1H is reasonable. Think of your CIWA patients; you wouldn't be allowed to push 4mg Q1H if it caused severe respiratory depression in every patient.

Someone on PSV should be sedated with another drug. You can argue Morphine is a respiratory depressant too, heck seems like all our drugs are, but Propofol is a heavy hitter. PSV makes the patient work to breathe, you can breathe the rate/TV on A/C and put no effort forth if you want.

Sounds like your pulmonary doc was more concerned about getting the guy extubated since he didn't really have a respiratory issue beforehand (just surgical), but he was being a bit laissez-faire about his BP and agitation. Someone with fluid overload who is too awake is going to be agitated as all get out (granted he needed it and it wasn't just replacements in surgery, but a laparoscopic shouldn't require you to need 6L replaced if I'm not mistaken). If he really wanted the guy extubated he should have come to see the patient and decide whether he could wait a day to be extubated, start a Lasix gtt, something.

Good on you for calling again and again. Hope you documented your butt off though!

Really? We frequenty switch to propofol from the benzos when we want to wean from the vent. I haven't seen resp depression on Propofol except at extreme doses- (50+ mcg/kg/min).

[detroitdano]

There's a reason staff/unit RN's cannot push Propofol in a spontaneously breathing patient. It's strong stuff.

[MomRN0913]

I always hated shutting off the propofol when weaning a patient. Some become extremely agitated and it interferes with their weaning. I have had patients be easily arousable on a certain amount of propofol. I say if they are weaning, their RR is >12 and they are pulling in their volumes, let them have the good stuff until they are closer to extubation, as in almost right before;) I have had a few pulmonologists give the OK for that on certain patients.

I think the problem in these situations as described above is that the MD is not there to fully assess the situation, the patient. They would have known patient needs to be on A/C because of wet lungs, given lasix, and can be placed back on propofol being the patient is resting on A/C.

[divaRN*]

i have had too many doc ask me to shut off propofol to assess readiness to extubate... then leave.. and make me chase them to get them back in the room to assess the pt after an hr off gtts, p*ssed off, bucking the vent and making too many attempts to self-extbate. grrr its aggrivating. so easy for the docs to say turn off sedation and walk out while we are the ones trying to keep the patient safe.

[my_purpose]

This post is extremely helpful, extremely. I'm a new grad in the ICU and in my second phase of titrating drips with more difficult patients. Had a case where the night prior pt was on propofol and ativan. We were weaning off propofol and titrating ativan to make patient comfortable. Come back and patient is off propofol, ativan 2mg no titration. 30 minutes prior to shift change, pt given 5 of verses for agitation. Pt starts bucking vent, doc comes down orders 5 more versed. No change in patient. Docs go sit st desk to discuss plan for pt ( I'm assuming). My preceptor literally pushes me outing the room to get more drugs for the pt. got order for 10 of versed, pushed, pt was fine. Eventually got order for propofol.

I know that was a lot, but my question was why ativan vs propofol, initially?

[my_purpose]

Great point!! As a new nurse trying to tie all things together, these posts are so so so helpful.

[core0]

This post is extremely helpful, extremely. I'm a new grad in the ICU and in my second phase of titrating drips with more difficult patients. Had a case where the night prior pt was on propofol and ativan. We were weaning off propofol and titrating ativan to make patient comfortable. Come back and patient is off propofol, ativan 2mg no titration. 30 minutes prior to shift change, pt given 5 of verses for agitation. Pt starts bucking vent, doc comes down orders 5 more versed. No change in patient. Docs go sit st desk to discuss plan for pt ( I'm assuming). My preceptor literally pushes me outing the room to get more drugs for the pt. got order for 10 of versed, pushed, pt was fine. Eventually got order for propofol.

I know that was a lot, but my question was why ativan vs propofol, initially?

One of the overlooked parts is you need to have a policy, which is essentially a template to start with. One thing you need is a scoring system to determine if someone is adequately sedated. This puts everyone on the same sheet of music so all the players understand how sedated the patient is. We recently changed from the motor activity assessment scale (MAAS) to the richmond agitation sedation scale (RASS). See here http://openmed.nic.in/2698/01/213-182-1-PB.pdf

The RASS seems to be easier to use and we get more consistent results. As part of this we changed the way we do sedation. Before we would order an analgesic and sedative and the nurse would titrate them to get the sedation required. This would lead to large doses of either Propofol or Fentanyl and small doses of the other. With our new protocol the fentanyl is titrated until the patient states they have no pain. If they display agitation then a sedative (usually propofol) is added and titrated to acheive a RASS or 0 to -1. I am amazed by how many patients (especially post surgical) can be managed by Fentanyl alone.

We also have a strong institutional bias against benzos. There is a ton of literature showing that they promote delirium in the ICU. Generally benzos are reserved for paralyzed patients or extremely ill (high dose 2 pressor or 3 pressors) where you don't want any hypotension from propofol. Also PTs with DTs.

My method for spontaneous breathing trial (for what its worth) is to wean off the propofol and fentanyl over an hour. I order PRN dilaudid for pain. Then SBT. If the patient becomes agitated the we re sedate. Try to figure out why they failed. Are they tachypneic because they are volume overloaded or is there anything else that you can do to optimize them. Once optimized, start Precedex and try again in an hour or two when the Precedex kicks in. This usually works pretty well. Occassionally if the patient won't tolerate Precedex (bradycardia usually) then I will use low dose Ativan but thats one or two time a year.

We also are strong proponents of early trach which is another way of safely weaning patients with agitation or long vent weans.

[calivianya, BSN, RN]

Propofol especially seems like it takes a really long time to get all the way out of the system if it's been going for a while. We know that lipid soluble things can build up in the body, so it makes total sense to get the pt. off the propofol as soon as possible to speed up extubation and be able to wake the patient up easier. We had an ARDS patient a while back that the nurses had been continually running on 70mcgs for a while to keep her fully under while she was proned, and after we tried weaning the propofol down it took her almost three days to even have a basic response to pain. You can definitely overdo it with the propofol and make a patient extremely hard to wake up for even days after it's off if people aren't paying attention and doing wakeup assessments like they are supposed to. I would rather switch the patient off the propofol and start using something else before extubation, like precedex/fentanyl/versed, but the physicians here are big on propofol being the only drip an intubated patient needs. I have yet to see a second sedative/analgesic drip going on any of our vented patients and it drives me nuts!

[haji]

Propofol is a great drug for quick weaning. It has an extremely short half life. There is absolutely no reason to leave a patient on psv overnight when they are clearly failing. With a respiratory rate in the 40s tachycardia and hypertension you need to put them on a rate and sedate them. Also why point out that propofol is a respiratory depressant? If the pt is going to be on the vent overnight then make them comfortable. Benzos are associated with increased delirium and increased mortality in some recent studies.

Precedex is nice bc no respiratory depression. But like propofol it causes hypotension.

I think it is a jump to say they need a lasix drip. Good for weaning but hard on the beans.

[wtbcrna, MSN, DNP, CRNA]

Propofol is very dependent on the time it has been infused. It can have long half-life if it has been infused for a long time. Context Sensitive Decrement Time Abstract