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Moderate Sedation-Propofol

CRNA   (7,243 Views | 8 Replies)

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I have never read a standard regarding maximum dosage of propofol for moderate sedation. I've read mean dosages, and policies regarding such average dosages, specifically for endoscopic procedures, but I have never read anything regarding a max dose of propofol for endoscopic procedures requiring moderate sedation. What would you consider to be too much propofol for an endoscopic procedure calling for moderate sedation only? Not deep sedation nor general anesthesia. Or, posing the question another way, what's the most propofol you have given for a moderate sedation procedure such as endoscopy?

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wtbcrna is a MSN, DNP, CRNA and specializes in Anesthesia.

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Anesthesia doesn't give moderate sedation. We give monitored anesthesia care or MAC. This encompasses the whole range of sedation from light to deep according to what the patient needs for the procedure. We generally do not limit ourselves to exact dosages. It is all based on what the patient needs.

Nurse administered propofol sedation or NAPS will often have protocols setup for maximum dosages, and you can find that literature with some of the protocols by doing a literature search. What I have seen from NAPS literature is that it is usually 3-4cc of propofol at a time every couple of minutes until the desired effect is reached or the propofol is placed on a pump an set to a low dose range.

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112 Posts; 3,854 Profile Views

Thank you for your response. I should have not termed the sedation as moderate sedation, but rather MAC, since I do forget CRNAs don't provide moderate sedation (think I read due to insurance reimbursement). I did read an article in Gastrointestinal Endoscopy by L.B.Cohen wherein the cited dose range was 30-250mg for colonoscopy and 10-190mg for EGD. My concern is not NAPS, since regarding this matter, it is not NAPS. While CRNAs may not be limited by exact dosages, I suppose my question should focus more so on when, as a CRNA, do you believe the dosing of propofol goes from MAC to general anesthesia? For example, if you administered 200mg propofol IVP bolus, would you prepare for intubation? Or, perhaps a more exaggerated value of 600mg IVP bolus of propofol? If 600mg of propofol IVP bolus were administered, what would be your thoughts as an anesthesia provider? Again, thank you for your thoughts.

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RN. has 29 years experience as a MSN, RN and specializes in Perianesthesia.

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My facility has a policy that states Propofol used for any procedural sedation must be consented for deep sedation.

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wtbcrna is a MSN, DNP, CRNA and specializes in Anesthesia.

1 Follower; 5,074 Posts; 53,485 Profile Views

Thank you for your response. I should have not termed the sedation as moderate sedation, but rather MAC, since I do forget CRNAs don't provide moderate sedation (think I read due to insurance reimbursement). I did read an article in Gastrointestinal Endoscopy by L.B.Cohen wherein the cited dose range was 30-250mg for colonoscopy and 10-190mg for EGD. My concern is not NAPS, since regarding this matter, it is not NAPS. While CRNAs may not be limited by exact dosages, I suppose my question should focus more so on when, as a CRNA, do you believe the dosing of propofol goes from MAC to general anesthesia? For example, if you administered 200mg propofol IVP bolus, would you prepare for intubation? Or, perhaps a more exaggerated value of 600mg IVP bolus of propofol? If 600mg of propofol IVP bolus were administered, what would be your thoughts as an anesthesia provider? Again, thank you for your thoughts.

I don't routinely do routine GI scopes. When I go to do GI scopes is usually due to a recent failed sedation or history of failed sedations. In those cases I try to determine what drugs those patients were given in the past and then I make a decision.

I have given 400mg of propofol IVP to young healthy marine that was all of about 120 lbs with little response and then had to redose with another 200+mg propofol for a the procedure that lasted less than 15 minutes.

What I do now for people that are hard to sedate is I pick my drugs based on sedation properties that work on different receptors. My personal favorite is propofol mixed with a small amount of ketamine. I rarely have used more than 2 (20ml) doses of that combination for double scope (EGD/colonoscopy). You can also add precedex, clonidine, versed, opioids (remifentanil is my preference) along with a variety of other choices. The main thing is you combine different receptors to achieve the desired effect when the drug you are using does not seem to be working.

To answer the question more directly: I have seen anesthesia providers, MDAs and CRNAs, keep pushing propofol till they got a semi-desirable effect, but to me it is like trying to say every woman should be a size 2 and every guy should wear a size 30" inch waist. It might be ideal, but not everyone is created exactly the same way and will respond differently to medications.

The term used in pharmacology is pharmcogenetics as to why people respond to drugs differently. Principles of Pharmacogenetics and Pharmacogenomics - Google Books

Edited by wtbcrna

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Bluebolt has 6 years experience.

2 Followers; 1 Article; 560 Posts; 26,838 Profile Views

That was a great response and I've noticed similar things in the ICU. Different drug types and classes, dosages work on patients in varied ways. I've even seen a few patients resist paralytic agents I've infused.

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NRSKarenRN has 43 years experience as a BSN, RN and specializes in Vents, Telemetry, Home Care, Home infusion.

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Always learning something new from wtbcrna... hadn't heard of Remifentanil

Potency

Remifentanil is approximately twice as potent as fentanyl, and 100-200 times as potent as morphine.

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