Propofol question

  1. I had outpatient surgery yesterday, with IV propofol. Went well, no pain, really is "milk of amnesia." Slightly goofy feeling was gone in several minutes.

    Two concerns:
    1) the anesthesiologist came in once while they were doing my nursing H&P, said he'd be back, didn't see him again until he appeared at my side with the syringe to give the med.

    2) during his step-in (above) the nurse shared a tidbit I'd learned googling, which I'd asked her about--that propofol's pain can be significantly reduced from something like 90% to 20% by using a large vein and warming it to 37 degrees. His response was that the med degrades if you warm it.

    This morning I double checked, and on Astra-Zeneca's site (question 23 if you use this link), it says exactly what I thought it had said. So he lied to me about the degradation thing.

    I'm kinda ticked off. I'm also inclined to share my documentation with him (already printed out the two pertinent pages).

    I guess I'm looking for feedback, realizing I'm in the "friendly camp" (I saw a couple of "us versus them" posts....). After all, I was his patient, and I don't appreciate being lied to. Doesn't accountability extend to physicians, or is it just nurses who are supposed to know their stuff and be honest?

    Thoughts? Suggestions? (Am I making too much of this? My anxiety usually has a half-life of about 3 days, so maybe I'm just still wound up.)

    Last edit by chris_at_lucas on May 4, '04 : Reason: misspelling
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    About chris_at_lucas_RN

    Joined: Nov '03; Posts: 3,081; Likes: 233
    RN/LMFT; from US
    Specialty: 7 year(s) of experience


  3. by   deepz
    Quote from chris_at_lucas
    ........I was his patient, and I don't appreciate being lied to. Doesn't accountability extend to physicians, or is it just nurses who are supposed to know their stuff and be honest?.......

    Welcome to the big wide wonderful world of anesthesia!

  4. by   chris_at_lucas_RN
    A wonderful thing just happened. I got a f/u call from the nurse at the hospital where I was cared for yesterday. Apparently this is part of the hospital's QA.

    I told her how upset I was about being lied to. She took me seriously. The information I shared will be passed to the anesthesia department.

    The call lasted about 30 minutes--obviously we talked about more than just the anesthesia issue.

    It made all the difference. Somebody cared. Of course it was a nurse.

    Terrific site--I'm printing it out to take to the nurse who called me. And maybe my surgeon. He oughta be using someone willing to be held to a higher standard!

    Thanks for the work you do, deepz.
    Last edit by chris_at_lucas on May 4, '04 : Reason: forgot something
  5. by   alansmith52
    oh dear. I hope you do get some feedback from that. I think the QA derpartment is in bed with the risk managment department. those people are trained to act like they care to differ the possiblity of a lawsuit.
    sounds like an md in a tight spot did what md's do when they don't know. lie.
  6. by   Tenesma
    actually he isn't entirely incorrect ---

    propofol degrades with oxygen exposure primarily due to loss of emulsification due to breakdown of soybean oil (lecithin is a great stabilizer, but not above 22 degrees celsius).... so should a sealed propofol bottle be warmed, remnant oxygen will accelerate decay of the product. The company tries to avoid this by deoxygenating the sample and storing the vial with nitrogen gas instead, but it is chemically impossible to get all oxygen out of the soybean oil/phospholipid (there are about 8 oxygen atoms per phospholipid molecule)

    so by warming propofol you accelerate decay of the propofol itself.... however i doubt that if you warmed the bottle to 37 degrees and then injected, that enough time would have elapsed for the accelerated decay to have a clinical effect.

    in fact, if you look at the literature regarding warming propofol and pain upon injection you will find 5 studies, of which 3 are statistically somewhat sound, of which 2 show that there is no difference whatsoever.... there is only one study on 100 gynecology patients, and if you read the study Anesthesia 1996 you will see that it is kinda fishy.

    there are far better techniques for avoiding pain upon injection:
    1) lidocaine with tourniquet
    2) labetalol
    3) ephedrine
    4) thiopental

    those are the only techniques that have been shown (besides large vein size) to make a difference...
  7. by   chris_at_lucas_RN
    Alan, thanks. I hadn't thought of that. Actually, though, I think that will be the strongest motivator for somebody to address the issue: to avoid future risk.

    As far as the oxygenation of lecithin, that makes a lot of sense from what I remember of chem, years ago. However, I got my information from the company website (no mention of the oxygenation problem), it was their recommendation backed up with cited studies, and it did look like it was meant for a professional audience rather than for patients. I tend to trust it for the same reason as the QA/risk mgt idea--the drug company wants to avoid risk that might cost them.

    Bottom line, I won't be using him again, I will be specifically asking for a CRNA, and I'll give my surgeon a heads-up about what happened. (Like he's gonna care.)

  8. by   Tenesma
    actually chris - maybe i didn't explain it properly

    it is the soybean oil that accerelates the decay when warmed (and oxygenated), and lecithin is there to help stabilize the oil/emulsification... it doesn't get oxygenated.

    so now that we know he isn't incorrect technically - how do you know he didn't use a different strategy on reducing pain upon injection? it doesn't sound like you had any propofol-injection pain... it also sounds like your anesthesia went smoothly -

    i would also warn against using drug information from drug-company sponsored websites - that is like believing the PDR to be true about everything, when in fact it is just the accumulation of inserts from drug companies.... There is far more believable research available in the literature that has a little less bias. Just for example they only cite ONE study (not the other 4 studies) which just happens to show a positive thing in their favor.

    but by all means, i think you are absolutely right in choosing ONLY CRNAs from now on....
  9. by   gaspassah
    tenesma, i think the real issue for chris was the lack of attention he was paid by his anesthesiologist, and the fact he felt he was lied to.
    that is if i'm following the thread correctly.
  10. by   pasgasser
    This reply is to address pain on injection of propofol and not the original concern of chris.

    I have found two ways to help avoid pain on injection of propofol. 1)give 1 mg/kg of lidocaine 2 minutes proir to induction and stop the IV immediately after the injection (poor man's Beir block of the vein), 2)give 5-10mg of ketamine 1 minute prior to induction with propofol. These are not things that are from literature but have prove effective for me. I have found mixing lidocaine with propofol very ineffective in reducing pain upon injection of propofol.
  11. by   chris_at_lucas_RN
    Thanks for your various replies.

    Yes, the issue is that I was lied to and ignored, at a time when I was horribly anxious. I am less enraged today than I was when I first posted. Thank you for being a part of my recovery.....

    As for the means of easing the pain of propofol and what conserves (or degrades) the med under certain conditions, I am always interested, and I appreciate the responses in those veins too.

    Deepz, I got your email--thank you especially!

    Almost all better now, feeling like a big girl again (yes, I'm female but for some reason I am usually assumed--by persons who cannot actually see me--to be male....), getting on with my life.


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