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.
Last edit by General E. Speaking, RN on Jun 28, '11
: Reason: forgot something