More Discussion of Propofol

[CRNAsoon]

Recently, there have been several threads on propofol usage on a few different forums here at AllNurses, which I have followed with much interest. Until last week, I had only given propofol in the ICU to ventilated pts; however, I have recently cared for patients who were not vented and using propofol.

One of my patients was completely fine one minute and then "suddenly" became very agitated. He was pulling at all of his lines, climbing out of the bed, and screaming incomprehensible things. Called the doc (anesthesia resident) and haldol was ordered. Gave with no response and a second larger dosage of haldol was ordered. No response either so a propofol gtt was ordered. I voiced my concerns about using on a non-vented pt but was told, "do you want to deal with this all night?". I acquiesced to his wishes and started the gtt. Kept the drug titrated between 3-5 ccs/hr throughout the night with no deleterious responses.

The other pt was extremely agitated beyond my wildest dreams. He was restrained with a posey vest, wrist mitts, and ankle restraints. No matter how tight I tied his restraints, he could yank the secured portion from the bedframe over and over. He was on a propofol gtt when I assumed care. As I was re-tying his restraints for the umpteenth time, the attending MDA stated, "you do know that you have an order for titrate to sedation, right?". I agreed but mentioned my reluctance to be using propofol on a non-vented pt. He practically laughed me off the unit. He told me that I could handle the case as I saw fit, but the gtt was already running and to not increase the dosage would just make the night more difficult for the pt and myself. The gtt was running at 5ccs/hr and I did begin to increase as needed, but as I increased my dosage, the pt really became hypotensive and hypoxic. I called anesthesia several times throughout the shift and was told the same thing over and over. Back up on the propofol and give haldol. I did this several times and just had the worst night ever. I asked the doc several times if there were any other options and was given none?

I guess my question here is "what else could I have done?". The unit I work in is CardioThoracic where we care for people directly after surgery before passing them on to step-down units. After reading other threads, I am aware of the dangers of using propofol on non-vented pts, but am being asked to do so by MDA's and residents. When I posed questions to other more seasoned nurses on the floor during this ordeal, they were very cavalier about this order and said they would titrate up. Are there any other drug regimens that can be used besides propofol for severely agitated patients in my situation? What could I have done differently in these two scenarios? I hope this isn't too basic of a question for this forum, but I am a new grad in the unit and am unsure about what I should be doing the next time this comes up.

[heartICU]

Well, in the first patient scenario you talked about - if he 'suddenly' became agitated, I would have questioned the reason behind it. Is he hypoxic? I have had patients who get reintubated simply because the only symptom they exhibit is mental status change...therefore unable to protect their airway. He could have been having a stroke/TIA/etc, and therefore sedating him with propofol wouldn't have helped his situation, even though it did seem to keep him calm.

In the second scenario you talked about, I would have suggested some other medications. I don't particularly like haldol because I don't think it gives a fast enough response. The patients I have given it to only seem to get less psychotic when you have given several doses...usually after about 24 hours. If I were you, I would have requested something else instead of the propofol. In our unit (a CTICU also) we used ativan 1-2mg Q1-2 hours. I have also used valium before as a sedative. (and the bonus for benzos is that there is a reversal in case of adverse reaction:-)

Obviously, by your post, you know the dangers of propofol in patients whose airways aren't protected. I have seen one nurse do what you did a few years ago (take an order for propofol in a nonintubated patient) and he did stop breathing....that story made it around the unit, and now the nurses in our unit refuse to start a prop gtt in these patients. (and that was only running at 20mg an hour!) We usually ask for another drug if the patient needs sedated and aren't intubated. Bottom line is....you can give any kind of drug to a patient, at any dose - but you have to be willing and able to deal with the consequences, whether its losing an airway, hypotension, etc. All drugs have their side effects and possible adverse reactions, but RNs in ICUs are educated on how to handle most of those things. Unfortunately, airway management isn't one of them.

When I was a CTICU RN (before CRNA school), I thought that airway management wasn't a big deal. I had seen tons of emergent intubations, fiberoptics, etc, and thought that every airway could be managed without too much difficulty. Then I went into the OR, and realized that airways are the fastest things to go down and the quickest way to get yourself into deep trouble. I didn't realize before school how little I actually knew about airway management.

Good for you for questioning the orders the anesthesia resident gave you...many new grad nurses don't quite have the confidence to do that yet. Just take it one step further and ask for another drug to use:-)

[athomas91]

You could kindly print this off and tell them to give it themselves because you worked too hard for your degree to have it taken because of their ignorance.

AANA-ASA Joint Statement Regarding

Propofol Administration*

April 14, 2004

Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Due to the potential for rapid, profound changes in sedative/anesthetic depth and the lack of antagonistic medications, agents such as propofol require special attention.

Whenever propofol is used for sedation/anesthesia, it should be administered only by persons trained in the administration of general anesthesia, who are not simultaneously involved in these surgical or diagnostic procedures. This restriction is concordant with specific language in the propofol package insert, and failure to follow these recommendations could put patients at increased risk of significant injury or death.

Similar concerns apply when other intravenous induction agents are used for sedation, such as thiopental, methohexital or etomidate.

*This statement is not intended to apply when propofol is given to intubated, ventilated patients in a critical care setting.

[gaspassah]

i agree with athomas. as an analogy.

dr writes an order for morphine to titrate for pain, up to 100 mg. but the order was to say 10. mg. if you give a dose of a medication and it's not the appropriate drug you are the one that is responsible. if you titrate a general anesthetic too high for sedation on a nonventilated pt. you are responsible. that mda when the lawsuit comes would hang you out to dry. if you administer a drug against the manufacturers recommendations you are pretty much up a creek without a paddle.

remember to always cover you orifice.

d