Ativan IVP vs Propofol gtt

  1. 1
    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
    Last edit by General E. Speaking, RN on Jun 28, '11 : Reason: forgot something
    lilredrn likes this.
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  3. 23 Comments so far...

  4. 2
    Ugghh.......sounds similar to the day I just had. I sometimes feel like Dr.'s start down a path and refuse to recognize when it isn't working!!!!!

    Not to hijack but I just spent almost 5 hours of a shift wrestling a huge head injury patient because someone wanted the propofol d/c and a versed gtt started. After 5 hours of insanity this guy bought himself a head CT........when on propofol we were cruising along and able to assess neuro's very effectively. So I feel your pain.
  5. 2
    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!
  6. 3
    As Dano said Diprivan can severely depress respiratory effort. However from your post it seems that the patient was tolerating PS while on both propofol and Fentanyl. I can understand the cutting back of Fentanyl, but propofol is so short acting that you really don't need to start "weaning" it down for possible extubation. And if you are pushing Ativan 2mg every hour than the patient might as well be on a gtt at that point. Ativan tends to linger quite a bit and make extubation harder.

    Stories like this make me happy I moved from the community hospital setting to my current unit. We have a resident on the floor 24/7 so when they try this kind of BS they can come see first hand how the patient is reacting.
  7. 2
    The pulmonologist might have been worried that the context sensitive half life of the propofol infusion would interfer with extubation. http://web.squ.edu.om/med-Lib/MED_CD.../020271r00.HTM
  8. 3
    25mcg/hr of Fentanyl? Pitiful. Should have D/C'd the fentanyl period and wrote for 1-2mg Dilaudid PRN. I would have left the propofol on and only titrated it down as tolerated to keep the patient easily arousable but slightly comfortable. Haldol is also a fantastic drug in ventilated patients. Last time I worked at the bedside in the unit we had all but quit using benzos. It was propofol, fentanyl, dilaudid, and Haldol...we had fantastic outcomes and were able to easily keep folks under control and quickly weaned, woke up, and extubated. Occasionally a pt did require ativan.
  9. 0
    Not quite clear, if the order was to wean the propofol and the patient was not tolerating the wean then why keep weaning?
  10. 1
    Quote from funkywoman
    Not quite clear, if the order was to wean the propofol and the patient was not tolerating the wean then why keep weaning?
    He told me to stop the propofol, not actually wean.

    I saw him yesterday and confronted him about the situation. We bantered back and forth for a while. He eventually told me that he was ****** that I had given so much anti-hypertensives and said if we restarted the propofol his pressure would have dropped.
    my_purpose likes this.
  11. 0
    Quote from meandragonbrett
    25mcg/hr of Fentanyl? Pitiful. Should have D/C'd the fentanyl period and wrote for 1-2mg Dilaudid PRN. I would have left the propofol on and only titrated it down as tolerated to keep the patient easily arousable but slightly comfortable. Haldol is also a fantastic drug in ventilated patients. Last time I worked at the bedside in the unit we had all but quit using benzos. It was propofol, fentanyl, dilaudid, and Haldol...we had fantastic outcomes and were able to easily keep folks under control and quickly weaned, woke up, and extubated. Occasionally a pt did require ativan.
    My original post said he told me to "wean" propofol, what he actually said was "stop" the propofol. Sorry for confusion. I did call back and get the fentanyl gtt upped to 50mcg but I agree that Dilaudid PRN might have been better.

    Thanks for the responses.
  12. 3
    In the CVICU, we would frequently use a Precedex gtt as we weaned off the Propofol, and then continued with the Precedex through the night until extubation in the am. Precedex will keep the patient relaxed and relatively pain free without causing respiratory depression.

    Sounds like a lasix gtt is also in order. IV ativan is for agitation. The patient was agitated because he was breathing through a straw while swimming in his own fluid. Lets fix the problem instead of masking it. Lets get rid of the fluid and keep the patient calm and pain free.

    Precedex and Lasix.

    Hope the patient did well.


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