Propofol Dosing in ER

[rhkenji]

So, I had a AMS patient who was awake but non-verbal, not following direction and had to be intubated. Prior intubation, we couldnt get an accurate BP reading due to the PT being restless.

After intubation, her BP was found to be in the 260s/150s, rechecked multiple times. After her paralysis wore off, doctor wanted her to be maxed on propofol per our unit policy (50mcg/kg/min), but that didnt help the restlessness.. she was still moving all extremities and the sedation is not working.

Her BP at 50mcg/kg/min was 220s/130s.

Doctor stated that we can go pass our guidelines of max 50mcg/kg/min. The MD and my charge nurse stated we can keep on increasing the propofol up to whatever is needed as long as the BP can support it and the patient is intubated.

I cannot find any articles regarding about it. How far have you pushed your propofol dosaging?

I usually request a secondary sedation after reaching 50mcgs.

[amzyRN]

Why didn't they pick a different med together? What else does your facility use besides propofol for sedation?

[rhkenji]

Versed. She was placed on versed afterwards. But I guess MD wanted the propofol for sedation and to lower her BP

[Nalon1 RN/EMT-P, BSN, RN]

Why not address the HTN with a true HTN med instead? If you hit the max of Propofol, something else should have been used. Sure up to 100/mcg/kg/min short term is probably not harmful with that high a pressure, but there are other meds out there to deal with it. Add Versed and Fentanyl for the agitation and then a little hydralazine or labetolol for the HTN.

What was used for sedation for RSI?

Was the reason for the AMS found?

[MunoRN, RN]

What was the analgesic being used? Sedation and particularly paralytics must include an analgesic, that may have been your problem.

[Wuzzie]

Kind of sounds like a "what came first the chicken or the egg" scenario. Was the hypertension the cause of her AMS by way of some intra-cranial process or was it elevated as a result of agitation? Either way using Propofol to treat it seems a bit of a stretch especially without any concurrent pain relief. Not sure what the rationale for it was and have never experienced it in my practice.

[rhkenji]

The BP was later addressed with nitro and cardene. The propofol scenario and verbal order was right after intubation. While waiting for nitro, versed and cardene from pharmacy.

[rhkenji]

This was immediately after intubation while new med were being added.

[MunoRN, RN]

This was immediately after intubation while new med were being added.

An analgesic should have come before intubation, not something added later. We have a couple of docs where I work who 'forget' to order an analgesic, we don't give them an option, if they say "start a propfol drip" we automatically ask what analgesic they want to go with that, if they don't order one then we put in for fentanyl per our medical director (and standard of care), this is even more important when using paralytics and/or when intubating.

[rhkenji]

Why not address the HTN with a true HTN med instead? If you hit the max of Propofol, something else should have been used. Sure up to 100/mcg/kg/min short term is probably not harmful with that high a pressure, but there are other meds out there to deal with it. Add Versed and Fentanyl for the agitation and then a little hydralazine or labetolol for the HTN.

What was used for sedation for RSI?

Was the reason for the AMS found?

she was placed on propofol immediately after RSI. given that additional meds will take 5-10 minutes to get from pharmacy, she needed more sedation to control restlessness. immediate v/o to max out propofol was given when it seemed like her high BP and having been intubated will support it.

Maxed out on 50mcg, and being that she still restless, the V/O was to go beyond 50mcgs and both my CN and MD stated that it's ok as long as BP can take it.

[rhkenji]

What was the analgesic being used? Sedation and particularly paralytics must include an analgesic, that may have been your problem.

This could be it as well, I agree. Analgesic was followed through afterwards. She was losing her airway and only medication included in our intubaton box are succ, etomidate and roc.

[BSN16]

our max is 100 mcgs