Diprivan question

NurzofFaith · Oct 9, 2002

Being a new grad myself and also in the CCU I had a patient just last week that was vented and supposedly sedated...NOT! He was wide awake, fighting the vent and had to be restrained. He has hx of ETOH abuse also. I asked a senior nurse after consulting both my drug book and IV drip book and finding no answers. She said that she has seen it as high as 85mcg/kg/min, I titrated up to 65 mcgs and that did the job:) Being a new graduate and not knowing the ranges even when consulting resources makes me nervous and very cautious...any advice on where to find better guidelines would be much appreciated.

~Channa

P.S. I also consulted with his team of docs who mentioned he might need a higher dose than normal..and gee did I know he was supposed to be sedated. :)

Estella · Oct 9, 2002

Hi!

I was a new grad, starting off in a Coronay Care Unit about three years ago. Diprivan/conscious sedation is one of those grey areas in class that they never really get into, because most nurses won't be using it.

One thing I did learn was to look everything up in the IV Drug book for answers. If I find what I want there, and the pharmacist doesn't know, then I call the number on the insert and start asking questions.

Does your unit have competencies you have to complete before you can give conscious sedation? Have you checked your policy manual to see what the hospital standards of practice are for the use of Diprivan? It can be a wonderful resource.

On my floor for alcohol abusers on the vent we still use Ativan with Diprivan to keep them sedated without snowing them too much. It is amazing how much they need to relax when they are withdrawing. (Watch out for day 3!!!!!) Addiction medicine is usually starting to follow them as soon as they come to the unit. These docs are also a great resource to find out how much of what meds are appropriate for these patients.

Hope that helped some.

New CCU RN · Oct 9, 2002

Just wanted to thank you all for your input. The patient was an off service patient from the Surgery/Trauma unit we got him b/c they had no beds.....unfortunately those docs barely have time to put in orders bc they are sooo busy so asking them really in this situation was not possible. Our unit resources didnt specify the upper limit and it was a night shift weekend...so unfortunately calling anyone on the insert wasnt gonna work either. We do have competencies for when we are using a paralytic and a sedative but not just for sedation.

I do want to thank you for your input. As far as some more concrete sources with gtts, I would love to hear from anyone that has some good drug guides. I have a CC Infusion guide and a drug book, but none of them are as detailed as need to be. Any thoughts out there?

Thanks so much.

whipping girl in 07, RN · Oct 15, 2002

I have Betty Gahart's IV book and I find it is very informative. Incidentally, you can go as high as 150 mcg/kg/min on Diprivan. I have had patients on as much as 100 mcgs. Our pulmonologists order it and usually write "titrate to effect" but sometimes they give parameters, usually if they do it's 25-75 mcg/kg/min.

I LOVE DIPRIVAN!!!

New CCU RN · Oct 15, 2002

Wow... 150 mcg? Like I said a CRNA was telling me she used 150 in the OR but that is the OR!!!! I'd be scared to go that high...nor have I ever needed to go THAT high...definitely think I'd be lobbying for a change of gtt before that point... your patient's BP tolerated even 100mcg? Our md's do the same titrate to effect...just never seen anyone go above 45 mcg! I am finding the drug books always seem to leave out some of the details you need to know for a gtt.... thanks for the info on the book....I will have to check it out. I am also considering getting a palm....anyone out there have any comments on the info they put out for the palm...if it is complete, etc? Thanks

traumarns · Oct 15, 2002

oh man, we have had pts go through a 100cc bottle an HOUR. and that med is really expensive.

By that point we ask for fent/versed. depending on the god complex or power trip the physician is on, we may or may not get the order to switch.

pts who are on dip/propofol can become quite tolerant to it. and require higher and higher doses the longer they are on it.

we do our own abg's. and use I-stat to run it. there have been studies that the i-stat will give false (i think pco2) on pts receiving more than 50mcg/kg/min of dip. we have a policy, that we send the abg's to the lab for those getting that much dip.

I have another question re dip and the lipid level.

do your nutritionists look at how much dip the pt is getting and either decrease the lipid in tpn, or take it out completely?

also, for those pts on cvvh, are you finding the machine to get clogged easier for those pts receiving diprivan vs other sedation?

Estella · Oct 15, 2002

Hi!

We have a nutritionist and pharmacist working together on a daily basis to keep the lipid levels r/t diprivan and TPN usage. When tube feeds start, they reevaluate the lipids there, too, just to be sure the pt isn't getting way too much fat. (We get a lot of gastric bypass pts. The last thing they need is a large fat intake. Their TPN is usually without lipids.)

whipping girl in 07, RN · Oct 15, 2002

Let me clarify...

First of all, I have not used diprivan at such high levels for very long. On occasion you have a patient that becomes SO wild that you have to get them under and pushing ativan as often as possible is like pissing in the wind. The times that I've had to go up SO high were temporary, just to get them under, then wean down until you get the level of sedation needed. I have had patients on as much as 80mcg/kg/min continuously for long periods. Fortunately, most of the time Diprivan is not needed for that long, and we try to wean it as low as we can to keep the patient sedated. I have had awake patients on just enough Diprivan that it keeps them from breathing 50 breaths a minute, like a patient I had the other night who we were trying to wean off Diprivan. She was awake most of the time, following commands, moving all extremities, and nodding/shaking head to yes/no questions appropriately. She was on 20 mcg/kg/min. When I tried to get her down to 10 though, she was back up to breathing 50 breaths a minute. MD wanted her breathing no more than 30, and she was on a lot of pressure support, pressure control and PEEP. So to tolerate that, some sedation was necessary, just enough to "smooth her out," I guess.

The best thing about Diprivan though, it that it's short acting, so you can turn it off and do neuro assessment.

lee1 · Nov 3, 2002

Originally posted by New CCU RN
I was wondering what you all use for your upper limit of Diprivan for sedation? At work the other day had an issue where the patient was just not being sedated yet MDs did not want to change to another gtt. (He was s/p MVA with high ethanol level and drinker....duh...of course it isnt working....but I am just a nurse) Anyhow, drug insert is no help, called pharmacy they said they weren't sure either...isn't that your job? Anyhow, one insert said that 50 mcg/kg/min is high dose but that some have needed higher, no guidelines though. What is the highest you have seen on a vented pt with stable BP? (for sedation not in or....i was talking to CRNA after this and she said they go up to like 150 mcg in OR)

First of all Diprivan is a great drug for initial sedation control. BUT, it is NOT the drug of choice here. Ethanol, etc????

You needed a drug that will help control the DTs this pt will most certainly be going through. We use Ativan drip in addition. There are also other drips that can be used. Diprivan is not the solution here.

What kind of MDs are these??? Residents with little practical knowledge??? What does the attending ICU MD say??? IS that person a ICU intensivist???

nimbex, RN · Nov 5, 2002

Lee, I respectfully agree and disagree. I agree that the DT's need to be agressivly addressed. But disagree with not using Diprovan based on current patient which is becomming more common... your etoh'er with pulmonary compromise. We now use diprovan even with the etoh'ers. especially so. We have a DT protocol with Ativan ordered to treat the HR, BP and temp. We sedate with diprovan.

Diprovan is the drug of choice because you shut if off, do your neuro exam Q shift and back down again.... can't do it the same with Ativan, mostly end up with respiratory compromise... here's the classic example... taking care of now;

Big etoh, aspirated, ARDS on oscillator, then on pressure control, AC, now cpap. (Before cpap today, we had a very narrow window of opportunity to shut off paralyzation, sedation to do neuro checks, would breathe 40-50's go into immediate resp. and metabolic alkalosis and crump). Not uncommon with ARDS. This person is now on CPAP, diprovan of 115 mcg/kg/min. last night breathing in the 40's with prn's, easily responsive, yet not able to follow commands (to slow down breathing) with full sedation!!! Only after speaking with the neuro doc and pulmonologist got the ok to add versed to control thr resp rate but had ph of 7.59 this am. Had to add versed at 5mcg to keep pt. breathing in 30's. aLL WHILE ON CPAP WITH ATIVAN AND MORPHINE.

So, don't always have time with these sick resperatory patients to let ativan wear off while their breathing 50x's per min. But we DO treat the etoh with the ativan,and you raised an excellent point!!!!!!! We just don't sedate with it. If ativan fails we even have used an ethanol drip.

FYI to konni your drinkers will require VERY high doses, it's ok, just watch for side effects like hypotension with the diprovan. We have a protocol that over 50 mcg/kg/min requires md ok, after that the pharmacy states 200 mcg/kg/min are ok. Yes anesthesia uses Diprovan in these high doses but don't let that scare you off.

Sounds like you've identified a future policy or protocol that needs to be in place with this patient population....it would make a great clinical ladder project!!!!!!!

thanks for listening to my OPINION hope it helps

lee1 · Nov 7, 2002

Originally posted by nimbex
Lee, I respectfully agree and disagree. I agree that the DT's need to be agressivly addressed. But disagree with not using Diprovan based on current patient which is becomming more common... your etoh'er with pulmonary compromise. We now use diprovan even with the etoh'ers. especially so. We have a DT protocol with Ativan ordered to treat the HR, BP and temp. We sedate with diprovan.

Diprovan is the drug of choice because you shut if off, do your neuro exam Q shift and back down again.... can't do it the same with Ativan, mostly end up with respiratory compromise... here's the classic example... taking care of now;

Big etoh, aspirated, ARDS on oscillator, then on pressure control, AC, now cpap. (Before cpap today, we had a very narrow window of opportunity to shut off paralyzation, sedation to do neuro checks, would breathe 40-50's go into immediate resp. and metabolic alkalosis and crump). Not uncommon with ARDS. This person is now on CPAP, diprovan of 115 mcg/kg/min. last night breathing in the 40's with prn's, easily responsive, yet not able to follow commands (to slow down breathing) with full sedation!!! Only after speaking with the neuro doc and pulmonologist got the ok to add versed to control thr resp rate but had ph of 7.59 this am. Had to add versed at 5mcg to keep pt. breathing in 30's. aLL WHILE ON CPAP WITH ATIVAN AND MORPHINE.

So, don't always have time with these sick resperatory patients to let ativan wear off while their breathing 50x's per min. But we DO treat the etoh with the ativan,and you raised an excellent point!!!!!!! We just don't sedate with it. If ativan fails we even have used an ethanol drip.

FYI to konni your drinkers will require VERY high doses, it's ok, just watch for side effects like hypotension with the diprovan. We have a protocol that over 50 mcg/kg/min requires md ok, after that the pharmacy states 200 mcg/kg/min are ok. Yes anesthesia uses Diprovan in these high doses but don't let that scare you off.

Sounds like you've identified a future policy or protocol that needs to be in place with this patient population....it would make a great clinical ladder project!!!!!!!

thanks for listening to my OPINION hope it helps

I agree that Ativan can cause the pt to not awaken as quickly. We also use Droperidol drips or Versed drips. We still use Diprivan but not in such huge doses then. Generally, where I work, the need is for those vented/ IABP pts to keep them quiet until IABP can be removed without pt thrashing around all over the place.