Diprivan Off Label for Seizure Suppression(?)

  1. I have a question about using Diprivan off label for seizure suppression? I work in CCU and we had a pt that became hypotensive (sbp 50's). She was on continuous EEG monitoring, which we normally do not see in CCU, nor have we ever used Diprivan for this off label indication. I'm used to using Diprivan for sedation/vent compliance. We normally turn off the Diprivan drip and call the physician if pt becomes hypotensive. We have critical care docs that are the primary, so I called the doc on call, updated him on events/condition and told him the Diprivan had been turned off. The pt was end stage renal on dialysis, intubated, and on Levo at the time. We started an Epi drip as per order. Her sbp temporarily increased 80-90's then dropped again. Further orders from physician was fluid bolus and cardiology consult in AM (d/t brady heart rate and widening of QRS). We also did 12 lead EKG. I also had the house officer come by to update her. Pt SBP stayed 70-80's. This all happened around 3am.
    Family was notified, they came in and decided at 7am to change code status to DNRCCA (she had been ill for some time, having a trach/Peg tube placed last August). When the neurologist came in that morning, he was irate that Diprivan had been turned off. He stated that it should not have been turned off because it was for seizure suppression. Our medical director called me the next night because the neurologist was upset. I asked if there couldn't be a standard of care order sheet stating "Do not turn off Diprivan" so it would be communicated to all staff and placed on our Kardex. (There wasn't an order written to NOT turn off for any reason. The medical director stated "I don't think we need to go that far. If you want to add that to the Kardex, that would be up to the CNM/nursing staff to do." If we might have future patients on Diprivan for this off label use, it would be nice to do some QA now and put a process in place.
    My main concern was pt's B/P. (Apparently the Neurologist wanted an incident report made out d/t Diprivan being turned off). We also use the Leap Frog system where the critical care physician is on all cases in our unit (and the attending)except the pts with strictly a cardiac Dx.
    Has anyone had any experience with this off label use of Diprivan? Is there a standard protocol used for a higher dose Diprivan in seizure suppression?Thank you!!!
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  2. 11 Comments

  3. by   CelticNurse
    I am sorry to sound a bit obtuse but it is probably because I do my ICU nursing in the UK. Can you explain to me what exactly using a medication "off-label" refers to.

    I am sure we have an equivalent phrase for it over here but I am in the dark here. Not for the first time either. I work with some nurses from the US, Canada and Australia and we all have differing phrases for the same thing! Just thought I would add to my ever expanding education. Many thanks....
  4. by   CCUnocRN
    off-label use is the practice of prescribing drugs for a purpose outside the scope of the drug's approved label, most often concerning the drug's indication. in the united states, the food and drug administration (fda) requires numerous clinical trials to prove a drug's safety and efficacy in treating a given disease or condition. if satisfed that the drug is safe and effective, the drug's manufacturer and the fda agree on specific language describing dosage, route and other information to be included on the drug's label. more detail is included in the drug's package insert. however, once the fda approves a drug for prescription use, they do not attempt to regulate the practice of medicine and so the physician makes decisions based on her or his best judgment. it is entirely legal in the united states and in many other countries to use drugs off-label.
    http://en.wikipedia.org/wiki/off-label_use

    diprivan is approved for use in sedation, such as for ventilator compliance and in surgical procedures. it has not been specifically studied in clinical trials for the indication of seizure suppression, but physicians can use medications "in the practice of medicine" for other purposes based on "sound scientific evidence".

    hope that helps. there is also good information on the www.fda.gov site under the irb information sheets.

    thanks!
    ccunocrn
  5. by   CelticNurse
    Quote from CCUnocRN
    Off-label use is the practice of prescribing drugs for a purpose outside the scope of the drug's approved label, most often concerning the drug's indication......
    .....physicians can use medications "in the practice of medicine" for other purposes based on "sound scientific evidence".
    That's what I thought it meant. We utilise the same practice with many drugs over here too, such as Gabapentin, Nortriptyline etc. for the use of treating neuropathic pain whaich was not what they were originally designed or commonly prescribed for.

    It is more commonly known as "use outside the terms of their licence" within the UK but, having more recently looked into some official websites over here, I have noticed that they are beginning to use the the term 'off-licence' more and more....usually in brackets. Typical. We do have a tendency to utilise different terms from the rest of the world when it comes to things medical. We have only recently officially changed to norepinepherine from noradrenaline! I still call it norad myself...

    Now I am more clear on the phraseology I have to say that yours is not an isolated situation nor would it be considered specific to practice solely within the US. I have been in situations that are nigh on carbon copies of that which you have described. I have worked in a hospital that had both a cardiac and a seperate neuro trauma ICU unit and we used to have to work in either depending on skill mix, workload etc. This type of thing was not an uncommon problem. Neuros wouldn't converse with their Cardiac colleagues and vice versa. They seemed happier to offload on the nurse who happened to be unlucky enough to be allocated to the patient at the time!

    The trouble is, I find, that doctors tend to prioritize their specialities as the prime factor driving all the care of a patient, regardless of the current presentation of the patient at any given time (which we all know can change for the worse in a New York minute!).

    It sounds like your neuro doc was merely playing to type and working on the basis that the only factor important to the patient's care was located from the neck up! The mere fact that the patient, certainly from your history and the subsequent orders given by your critical care doctor, appeared to be in a general terminal decline seems to have eluded his own clinical assessment! Like I said, not an uncommon problem....

    Having had many years in the field and having used Diprivan for a wide spectrum of critically ill patients, I have never seen it used as a primary drug for the management of seizures. Indeed, I have seen people go full grand mal on me whilst well under the very same drug! Moreover, there is an argument that can be put forward that a patient can still be suffering from seizures and the actual incident can be hidden by being well sedated. Just because the patient is still and compliant in all other aspects doesn't mean that their synapses aren't being scrambled at the same time!

    Might I ask, was the patient actually on any specific anti convulsant medication, I wonder?

    Either way, to my knowledge their isn't a specific protocol for high dose Diprivan for the use you described over here.....and I have worked in quite a number of large volume ICU's all over the UK. Generally, as far as I have been made aware by my foreign colleagues this seems to be a universal situation.

    What can I say? Sounds like you got a dose of your neuro chap when he was at least two coffees behind the rest of the waking world!!

    Still, nil desperandum, eh?
  6. by   meandragonbrett
    Apparently propofol can be used to treat seizure activity. Do a search on google scholar to find more journal articles.

    http://www.blackwell-synergy.com/doi....x?cookieSet=1
  7. by   NeuroICURN
    Hey guys!

    To the poster that asked if the patient was on any kind of anticonvulsant - It is not uncommon to have a patient who is multiple anticonvulsant drugs and the patient remains in status (continues to have seizures).

    Now, that being said...It is not uncommon at all to use Propofol for seizure control. When someone comes in in status and the traditional drugs (i.e. Dilantin, phenobarbitol, etc.)....they very often end up intubated and we sedate them on Propofol. However, unlike other neuro patients on propofol, we don't do frequent wake-ups....that would be counterintuitive! So, what do we do when seizures are controlled by the drug but their BP drops....of course we try the fluid boluses and if that doesn't work, they get a pressor, but we usually start with Neo (phenylephrine).

    So, what to do when propofol doesn't even work? Well, we have other options. I've seen cases that were so bad that we've resorted to Ketamine gtts and Pentobarb comas. Also, I think it goes without saying that most of these patients get continuous EEG monitoring.

    We even had a guy one time that had seizures for 2.5 months!!! Believe it or not, he actually came out normal!!!
  8. by   LadyNASDAQ
    I believe you did the right thing. When the BP drps, you have to use good Nursing judgement and one of those things is not to let that BP drop or you will be losing perfusion to the brain. There has to be standard orders to use off label uses and the Dr. should have ordered this in his orders. A prudent Nurse never lets her patient get into trouble and tank a BP. When you called him, did you state which drips were turned off? Next time you should always do this and now that you know this person is practicing with meds off label, watch your back carefully.
  9. by   gasmaster
    In high doses propofol has antiseizure activity. We often use it for drug-induced coma with SE.
  10. by   luvtheOBX
    My question would be, how was the order written? Did it specifically say the Diprivan was for seizure control? Typically our diprivan orders are written, "titrate to maintain Ramsey of 3" No where in the Ramsey scale does it mention seizures. If this neuro doc does this again then get him/her to write a specific order. Thin it will be his a** is on the line when the pressure bottoms out. Or I suppose you could call him at 0200 to see if he wants the diprivan titrated then call every 15 minutes to see if you can titrate it again, "sorry to call again Dr God but the patient is still not having seizures at 20 Mcg of Diprivan and his BP is 80/40 can I titrate down?"
  11. by   gasmaster
    Quote from luvtheOBX
    My question would be, how was the order written? Did it specifically say the Diprivan was for seizure control? Typically our diprivan orders are written, "titrate to maintain Ramsey of 3" No where in the Ramsey scale does it mention seizures. If this neuro doc does this again then get him/her to write a specific order. Thin it will be his a** is on the line when the pressure bottoms out. Or I suppose you could call him at 0200 to see if he wants the diprivan titrated then call every 15 minutes to see if you can titrate it again, "sorry to call again Dr God but the patient is still not having seizures at 20 Mcg of Diprivan and his BP is 80/40 can I titrate down?"

    Well, if I'm using the propofol for burst suppression then of course the BP is a factor that must be considered. However, stopping status is the priority so our doc's will write orders for use of Dopamine or Neosynephrine if needed. The status must cease, that's the bottom line. Remember that pentobarb and phenobarb coma's also have the same issue of low BP, and the same actions are employed in those cases as well. It is not unsual to have these patients on such high doses as 100mcg or more of propofol. There is no ceiling.
  12. by   pebbles
    I think you did the right thing.

    After all, you have to take care of the A-B-C before you do the D (which is neuro/disability), and with a low BP, your C is in jeopardy.

    It should always be communicated and known why a pt is on a specific drug, ESP if it is off-label use. And if it's becoming less safe to use the drug, it needs ongoing re-evaluation.

    The doc that was upset you'd turned off the diprivan - was only thinking about the one body system he's treating, and not the whole pt. Really, he should have been upset with the other doctors and not you. If the BP would have been higher, you could have turned it back on.

    It's great to say that diprivan can suppress seizures. But in this case, the pt was not able to tolerate that therapy, and the treatment needed re-evaluation. (more fluid to make sure "the tank is full", colloids, etc could have made a difference as well. All of which is something that should have been managed by your on-call doctor.).
  13. by   walk6miles
    I am learning something new everyday..... question, if the order was to be for seizure control, why not use a pressor for increase/control of BP?

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