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.

[offlabel]

All the above + check and make sure the IV is still in after all of the thrashing.

[Oh'Ello, BSN, RN]

No ****, last month I had a patient awake and sitting in a bedside chair, communicating by typing on an iPad... INTUBATED on A/C and running 60mcg of propofol. So maxes are relative.

Anywho, I'm kinda surprised in an ER they don't have drips available in the accudose and that you have to wait for them to come from pharmacy

[guest769224]

No ****, last month I had a patient awake and sitting in a bedside chair, communicating by typing on an iPad... INTUBATED on A/C and running 60mcg of propofol. So maxes are relative.

If the patient was appropriate and following commands why not taper it down or turn it off (temporarily)?

[brit7]

I'm not sure what your ED commonly uses for maintenance sedation post-intubation...but would Fentanyl and Versed drips not have been an option? My experience is with hypertensive and sedated pts the combination of fentanyl and versed achieves a good level of sedation while also lowering BP...plus they are compatible drips, so you can use 1 iv site and leave other iv sites open for other medications.

[BSN16]

also to contribute more...these max limits are different at every hospital. Pharmacy generally sets the max limits as their recommendations. for example at the other hospital in town their max on precedex is .8 where our's is 1.4.

Our "max" on levophed is also 30 mcg/kg/hr. Although this is considered maxing out on this medication per my hospital i have ran it much higher with a doctor's order

[That Guy, BSN, RN, EMT-B]

Fent and versed fent and versed fent and versed!!!!!

[Oh'Ello, BSN, RN]

If the patient was appropriate and following commands why not taper it down or turn it off (temporarily)?

Because she had massive spontaneous pneumos and resisted mechanical ventilation (understandably) without the propofol.

[marienm, RN, CCRN]

No **** last month I had a patient awake and sitting in a bedside chair, communicating by typing on an iPad... INTUBATED on A/C and running 60mcg of propofol. So maxes are relative.[/quote']

Sorry to sidetrack, but did the patient remember this after the infusion was stopped? I've had a pt on 80mcg/kg/hour (our max is usually 80, sometimes 100) following commands and mouthing appropriate words "I need to go to the bathroom." After extubation she didn't remember any of it. I'm not surprised she didn't, but just curious!

Re: the OPs post, some sedatives work better for certain patients than others. Was the AMS caused by some kind of substance abuse? (Maybe the HTN was as well?)

[Guest219794]

A couple of thoughts-

As mentioned, Fentanyl, which should be easily available in the ER.

Another thing that might have worked better than speeding up the drip would be to have the doc push a bolus.

Doubling the dose from 50 to 100 mcg/kg/min on a 100 kg pt results in an extra 5 mg/min. Given the short duration of Propofol, it takes quite some time for concentrations to build up and have effect.

If you had two identical 100 kg PTs, both inadequately sedated on 50 mcg/kg/min:

PT A gets an additional 25 mg as a bolus.

PT B gets 25 mg slow push over 5 minutes- the same as doubling the dose.

Pt A is going to have a much quicker effect.

[Lev, MSN, RN, NP]

What was her BP before intubation?

Most patients do fine with just Propofol for sedation. If they have PRN agitation, an extra bolus of Propofol or some Fentanyl can fix that as the Propofol is being titrated up. For those who cannot be sedated with Propofol, Precedex usually does the trick. I have also seen Ketamine used for this purpose.

[FatsWaller, BSN, RN]

The ER I work in if the patient isn't adequately sedated by just propofol and the threat of extubation exists then we just tack on fentanyl and versed drip. Same vise versa. I prefer Fentanyl and versed drips and I advocate for it if possible but if its not doing the job we tack on propofol as well, assuming the access exists of course.

[AntonellaB]

Pain meds are given: Fentanyl, Morphine...also some benzos. When pts agitated some docs order Versed.