Propofol Infusion syndrome?

[Pharmahaulic]

So I obviously know that you use a lot of propofol for sedation in the ICU, and a lot of patient might need deep continuous sedation for extended periods of time depending on what's going on with them... I know that with propofol there's protocols and risks and you can't give high dose long term infusions for extended periods of time because of the risk of propofol infusion syndrome.

So with that said what do you do if a patient needs really needs long term sedation, and other sedatives like benzos/ narcotics aren't cutting it? What do they do? Do they just use the propofol and give "breaks" and then start the infusion again?

[MunoRN, RN]

The problem in this case wasn't that nothing was effective, it's just that propofol was MORE effective. Peds is a different beast. Brains are much more elastic and can tolerate much more hypoxia and insults than the adult brain. Having mostly reduced and significantly less "intense" seizures on another protocol is proven safer in peds than strictly relying on propofol. Tolerating a few seizures a day is preferred over having no seizures on propofol. However, length and duration of course is highly pertinent.

This example was a clear-cut case of mismanagement. Last I heard, the family was litigating the outside hospital.

If they don't really need the propofol the they don't really need the propofol, but that's a different basis for decision making than a rather unfounded time limit. The risks of propofol vs the benefits are the sole basis whether it's the first hour or the 40th hour of the infusion. And there really isn't any evidence that status epilepticus in peds is benign, there is a higher rate of survival but a similar rate of permanent neurological injury, so while peds are more likely to survive it's survival with permanent disability, which is still a poor outcome compared to survival without permanent neurological injury.

[PixieRN1]

If they don't really need the propofol the they don't really need the propofol, but that's a different basis for decision making than a rather unfounded time limit. The risks of propofol vs the benefits are the sole basis whether it's the first hour or the 40th hour of the infusion. And there really isn't any evidence that status epilepticus in peds is benign, there is a higher rate of survival but a similar rate of permanent neurological injury, so while peds are more likely to survive it's survival with permanent disability, which is still a poor outcome compared to survival without permanent neurological injury.

First, don't say that I said status epilepticus was benign...because I certainly said nothing of the sort. Period.

Here.

Early stages of propofol infusion syndrome in paediatric cardiac surgery: two cases in adolescent girls | BJA: British Journal of Anaesthesia | Oxford Academic

Propofol-Related Infusion Syndrome in Critically Ill Pediatric Patients: Coincidence, Association, or Causation?

http://pediatrics.aappublications.org/content/112/4/1002?download=true

Both articles mention up to 48 hours as a max guideline but state it can and does happen much sooner.

The second journal notes that propofol is NOT FDA approved for use in sedation in PICU populations.

I'm done arguing.

[Pharmahaulic]

In our unit we have Sedation Vacations ordered every 24 hours of sedation. We titrate down the propofol using the rule of 5 until off. We then wake the Pt and assess mental status and let the pt know about their condition. If the pt tolerates well, we may use other medications to maintain a therapeutic response. if not, then we place Pt back under full sedation and try again tomorrow.

How long is the vacation sedation? Also, when you put them back under after the sedation vacation like you stated, do you start using the propofol again?

[Pharmahaulic]

:) Actually some DO think high carbs help! There's at least a few journal articles that has been written about it (but it's hard to study something that occurs rarely and that you don't really want to induce on purpose).

"Adults have larger carbohydrate stores and require lower doses of propofol for sedation than children, which might account for the rarity of this syndrome in adults. The mean total daily calorific intake in our case was only 167·1 kJoules/kg (39·8 kcals/kg), with a carbohydrate intake of 0·9 mg/kg per min on day 1, 2·6 mg/kg per min on day 2, 2·4 mg/kg per min on day 3, and 4·2 mg/kg per min on day 4, which would be insufficient to prevent fat metabolism. A carbohydrate intake of 6–8 mg/kg per min should provide adequate calories to suppress fat metabolism in critically ill children. We suggest that such carbohydrate intake might prevent propofol infusion syndrome."

Wolf A., Weir P., Segar P., Stone J., and Shield J. (2001). Impaired fatty acid oxidation in propofol infusion syndrome. Lancet, 357, pp. 606-607.

See also:

EB Stelow, VP Johari, SA Smith, JT Crosson, FS Apple. (2000). Propofol-associated rhabdomyolysis with cardiac involvement in adults: chemical and anatomic findings. Clin Chem, 46, pp. 577-581.

(apologies for the poor citation format...I mostly just copy/pasted)

Thank you very much for the references! Where did you find these?

Also, why do adults require less propofol for sedation than adults if they are larger. Wouldn't that mean they require more?

[wtbcrna, MSN, DNP, CRNA]

Propofol infusion syndrome isn't as common anymore because we don't use propofol infusions in as high doses or as long as we used to. Propofol like most infusions will slowly enter all tissue compartments and absorb. To start to figure the duration of effect after being on an infusion you have to use context sensitive half life tables. Half-time or Half-life:What Matters for Recovery from Intravenous Anesthesia? | Anesthesiology | ASA Publications

Propofol infusion syndrome: a structured review of experimental studies and 153 published case reports

I am not sure why ICU providers don't use remifentanil more instead of fentanyl infusions. Remifentanil has duration of effect of approximately 15minutes after the infusion is turned off. The cost is minimal these days so that should never be an issue. There is also should be a Remimazolam in the future that can be used instead of versed gtts. Remimazolam is supposed to have similar pharmocokinetics as remifentanil.

Remimazolam - Wikipedia

[Pharmahaulic]

Propofol infusion syndrome isn't as common anymore because we don't use propofol infusions in as high doses or as long as we used to. Propofol like most infusions will slowly enter all tissue compartments and absorb. To start to figure the duration of effect after being on an infusion you have to use context sensitive half life tables. Half-time or Half-life:What Matters for Recovery from Intravenous Anesthesia? | Anesthesiology | ASA Publications

Propofol infusion syndrome: a structured review of experimental studies and 153 published case reports

I am not sure why ICU providers don't use remifentanil more instead of fentanyl infusions. Remifentanil has duration of effect of approximately 15minutes after the infusion is turned off. The cost is minimal these days so that should never be an issue. There is also should be a Remimazolam in the future that can be used instead of versed gtts. Remimazolam is supposed to have similar pharmocokinetics as remifentanil.

Remimazolam - Wikipedia

I read that Remifentanil has much less likelyhood of causing nausea and vomiting compared to fentanyl or other opioids because of its rapid metabolism and offset of action. Is thus true?

[wtbcrna, MSN, DNP, CRNA]

I read that Remifentanil has much less likelyhood of causing nausea and vomiting compared to fentanyl or other opioids because of its rapid metabolism and offset of action. Is thus true?

Nothing that I saw would suggest RF is less nausea provoking than Fentanyl.

[Pharmahaulic]

Nothing that I saw would suggest RF is less nausea provoking than Fentanyl.

Speaking of, do you use any barbiturates where u are?

[wtbcrna, MSN, DNP, CRNA]

Speaking of, do you use any barbiturates where u are?

No barbiturates usually the icu does propofol or versed/fentanyl. I will occasionally see precedex used.

[Pharmahaulic]

No barbiturates usually the icu does propofol or versed/fentanyl. I will occasionally see precedex used.

Does precedex cause a lot of nause or vomiting as a side effect? Compared to other sedatives or anesthetics?

[wtbcrna, MSN, DNP, CRNA]

Does precedex cause a lot of nause or vomiting as a side effect? Compared to other sedatives or anesthetics?

Not usually unless the BP gets low.

[Pharmahaulic]

Not usually unless the BP gets low.

Oh yes, I forgot low BP could be a nausea and vomiting trigger.