Sedation..Your thoughts?

[Da_Milk_of_Amnesia]

So I just have a question for my fellow icu RNs. I had a patient last night who while even sedated on 50mcgs/kg/min of propofol and 6 of versed was able to open eyes and follows commands and respond appropriately. I asked her several times if she was comfortable to which we nodded 'yes'. Her Peak pressures were all fine in, her HR was 90s-100s, which is better than the 110-120s she was when she got to me and her BP was now 100-110s which was better than the 70-80 when she got to me (septic, severe PNA). I made the decision to not call the MD and not add anymore sedation to her. She was triggering the vent at a rate of 20-22 on PRVC. So my question is, what would have you done? I know some people like to have their patients snowed wayyy down, but I don't like to. She was a young girl in her 30s, and since she was hemodynamically stable (on only 2.5mcg/min of levo, down from the 10mcg/min she was initially on) I decided to keep her where she was. I know it's a judgement call and everyone will have their own opinion on what they would have done, but i am curious to know. Thanks.

[sugarmagnolia3]

Ummmm I

ok in all seriousness...you did great! She was nodding comfortable...no need to necessarily add a pain drip too...the more meds added, the more she could be slowed down from weaning...

the only thing I would say is...did you double check her weight being used for the propofol.

Had someone wide-fricken-awake on 50mcgs of propfol a while ago...was giving PRN ativan, morphine etc to keep him calm...Went the whole shift and realized the kgs programmed into the Alaris pump, was wayyyyy lower than the patients actual kgs

Doh!

Live & learn =)

[MomRN0913]

I have seen propofol at 60mcgs and a self extubate! Some patients are very resistant. For whatever reason, drug abuse, alcohol abuse, a young resistant body.... I have seen 60 mcgs of diprivan with ativan on board too and the patient is awake. All into a central line, patient is getting the drug.

If you patient is comfortable, can follow some simple commands, not bucking the vent, not self extubating, BP decent, it seems as if you have the patient where you want them. When you feel the time to wean is coming along, start to titrate down. Good calls to me!

[mpccrn, BSN, RN]

She looks good to me....I'd have done the same as you!

[chudder]

I would have left her exactly where she is and maybe added some dilaudid or fentanyl for pain control if needed.

agreed. add fentanyl and d/c propofol and you could probably wean the levo to off

[stl2nola72]

What about momentary tiny pump bolus of propofol? How do people normally bolus it? I was taught since I was a new grad to jack the pump rate all the way up and give a tiny squirt and then adjust the rate back down. Every ICU nurse I knew always did that me included. I had a patient last month in my procedure area that I received from SICU who was vented and on a gtt and didn't have a great BP. I didn't want to give him a bunch of versed like we did with most of our patients. The radiologist was all worked up cuz the patient was acting up during the procedure. I gave him a tiny squirt to calm him without incident. The next day I was put under investigation and three days later I was terminated and now I can't get a job. 9.5 years of critical care nursing down the drain and I'm losing my house!

[ShaunES]

I just use the bolus feature in our pumps, saves me having to baby sit the pump, and I don't accidentally leave it infusing at 1200mL/hr.

[stl2nola72]

That's why I was afraid of bolusing it that way cuz I've seen it happen to other nurses and we had the oldest pumps known to man, with no bolus features. I was working with another nurse who insisted I do it that way and then she was the one who reported me for doing it.

[RN1980]

during our yrly sedation classes at my hospital we are informed it is not appropriate for us to bolus diprivan unless we get a order from a md with advanced airway equipment near and unless the pt is on the vent. we have had pts many times on diprivan >100mcgs and others totally snowed while on a pathetic 10mcgs....it shows each pt is different and you have to adjust not only your sedation of said pt but your practice aswell.

[richard1980]

It's our facilities policy that we cannot bolus propofol in a syringe but we can use the bolus feature on a pump and give them a few ml's at a rapid rate. I guess the highest rates of propofol I've seen is around 100 mcg/kg/min or so but usually we'll add a fentanyl gtt and precedex or versed or ativan if the patient is requiring high levels of diprivan. I think you did fine sedating your patient. IMO intubated patients, as long as they're comfortable/cooperative should be kept at a MRS of 3 a vast majority of the time. No reason to keep them wide awake with an ETT but no reason to snow them either unless it's medically necessary or they're interfering with their lines.

[Mrs.Rollins, ASN, RN]

during our yrly sedation classes at my hospital we are informed it is not appropriate for us to bolus diprivan unless we get a order from a md with advanced airway equipment near and unless the pt is on the vent. we have had pts many times on diprivan >100mcgs and others totally snowed while on a pathetic 10mcgs....it shows each pt is different and you have to adjust not only your sedation of said pt but your practice aswell.

I'm confused: why on earth would you be bolusing someone with propofol unless they were intubated or for the purposes of RSI?

[RN1980]

exactly, why would you bolus unless you are intending intubation or already on vent...thats why our inservices are instructing us not to do it. there has been plenty of nurses that have been far to cavalier with pushing this drug that has resulted in disasterous results. i think the op stated that they gave a mini bolus of this drug for a conscious sedation, which is a no no at my hospital.

[detroitdano]

KNOW your nurse practice act. Pushing Propofol on a spontaneously breathing patient is a big no-no in most of them. MD's, CRNA's are allowed for the most part as they are trained in airway management.