Your PROPOFOL stories wanted

Posted
by RNNCcicu98 RNNCcicu98 (New) New

What is the maximum infusion rate allowed for propofol at your hospital?

  1. 1. What is the maximum infusion rate allowed for propofol at your hospital?

    • =50mcg/kg/min
    • 50-79mcg/kg/min
    • 80mcg/kg/min
    • 81-100mcg/kg/min
    • >100mcg/kg/min
    • There is no max rate at our facility.
    • I don't know if there is a max rate.

19 members have participated

I am preparing a presentation on using propofol as a continuous infusion for sedation on vented patients. Although I have my own personal experience administering/maintaining this drug, I was hoping for some feedback and/or stories about YOUR experiences with propofol. My goal for this presentation is to educate and prevent unexpected adverse events.

Our CICU uses propofol occasionally (midazolam is the drug of choice...), and of course we use an analgesic as well. I have researched this drug extensively, and am aware of the common side effects. BUT, we all know that experience brings information that at times is not found in research alone.

What tips/cautions/lessons have you learned about propofol? Share away! Thanks so much for your contribution.

icuRNmaggie, BSN, RN

Specializes in MICU, SICU, CICU. Has 24 years experience.

I attended a lunch (really 5 pm at a pub) and learn and our intensivist shared that propofol being lipophilic and protein bound stays in the tissues for a week after it is stopped, and that it causes foot drop and wrist drop. We have all seen that. I have seen symptomatic bradycardia as well. The triglycerides are sky high with propofol. I don't think it benefits patients to be on high doses of propofol and in deep anesthesia for a week. Will post more later.

Edited by icuRNmaggie

Wile E Coyote, ASN, RN

Specializes in Critical care.

The tip I have after using it exclusively at a prior icu/cvicu was to always keep an idea of when it's about to run out. If that's the only sedation on board, attend to that beeping pump quickly! That pt on high infusion rates will wake up and start pulling within minutes at the measly "end of infusion tko rate" that many pumps revert to. Are you exploring an alternative to midaz and fentanyl due to the latest big published study on icu psychosis/ptsd?

Biffbradford

Specializes in ICU.

Nothing earth shattering to share from here. Stay on top of a spare bottle for the on coming shift and I'll change the tubing a little early if it's going to be due on the next shift (usually Q12hrs). Love it though! :sneaky:

Here.I.Stand, BSN, RN

Specializes in SICU, trauma, neuro. Has 16 years experience.

We check a triglyceride level q 72 hours while on propofol to monitor for risk of developing rhabdo. I personally have never seen symptomatic bradycardia with it, although I have heard of it happening. In practice I see hypotension quite a bit though. We use the lowest dose possible; usually we aim for a RASS of 0 to -1. If they're having ICP issues or otherwise need moderate/deep sedation, we usually switch them to a versed gtt. If they have hypoptension or other contraindication to continuous sedatives, we do prn versed IVP...like 1-4 mg IV q 1 hr prn. We use a gtt for pain control as well, usually fentanyl. Our docs will usually trach someone if they've been intubated for a week and are not able to wean from the vent, so nobody is in propofol for really prolonged periods.

PaSSiNGaS, MSN

Specializes in Nurse Anesthesiology. Has 16 years experience.

I attended a lunch (really 5 pm at a pub) and learn and our intensivist shared that propofol being lipophilic and protein bound stays in the tissues for a week after it is stopped, and that it causes foot drop and wrist drop. We have all seen that. I have seen symptomatic bradycardia as well. The triglycerides are sky high with propofol. I don't think it benefits patients to be on high doses of propofol and in deep anesthesia for a week. Will post more later.

Your intensivist has his facts slightly confused. While Propofol does have a very large volume of distribution it does not continue to work for a week once turned off. It is very protein bound (>90% bound), but just because a drop stays in someone's system for a day or a month doesn't mean it is eliciting an effect. That is where the CSHT comes into play. It actually has a context sensitive half time of about 40min even with an infusion > 8 hours. The cause of the foot drop and wrist drop would happen to anyone on a sedative/hypnotic like propofol or something like versed. It relaxes the patient and that's where you may see foot drop.

beckster_01, BSN, RN

Specializes in MICU. Has 12 years experience.

I love propofol. I have certainly seen symptomatic bradycardia as well as significant hypotension in certain patients, but if a patient has required continuous sedation for more than 48 hours we usually try to switch to propofol quickly as part of our delerium prevention protocol. I have found it is easier to wean and doesn't make people quite as crazy as midazolam. Usually combined with a fent or dilaudid gtt my patients don't require high doses.

Nursetastic

Has 4 years experience.

Watch out for green urine. Some patients develop almost fluorescent green urine. That's all I have to add. But I agree with hypotension and triglyceride levels.

MunoRN, RN

Specializes in Critical Care. Has 10 years experience.

I didn't think midazolam was the "drug of choice" anywhere anymore due the research that's come about regarding benzos and delirium.

essT

Specializes in NICU. Has 5 years experience.

Most of our LIPs use it as their first line choice.

I can't say that I've seen it cause significant bradycardia (nothing like Precedex). A mild drop in heart rate isn't uncommon, though, but I see that as a sign of achieving adequate sedation. Hypotension is usually my main concern, and we see vent/propofol/levophed/dilaudid IVP as a common combination. For patients having profound hypotension we'll use midazolam and fentanyl instead.

Our sedation order set is to titrate to achieve a RASS of -3 with a daily sedation vacation at 0700 (unless otherwise ordered). Max is 80 mcg/kg/min but occasionally we'll go up to 100 with an LIP order.

Our dietary folks always take propofol use into account and reevaluate these patients daily. One of our docs checks trigs daily, most do q72 hours.

Edited by essT

assidere

Specializes in Telemetry, ICU.

Never had any personal experience in problems with bradycardia. Hypotension on the other hand, is real and has caused problems fairly often for me.

We aim for RASS between -2 and -3 (just changed from MRS 3-4), and check Trigs q48 hours on everyone. Our max is 80mcgs, and we do daily wake-ups in AM unless ordered.

I have found that the larger patients hold onto it longer (IE- the fat soluability), but never had real problems "for a week" like one post said. Green urine happens occasionally, but is really only good for confusing the new grads and students when I quiz them on it... ;)

calivianya, BSN, RN

Specializes in ICU.

I had someone take three days to wake up after the propofol was turned off once. She was over 600lbs. Propofol may have a very short half life, but it really is no joke in these super-obese patients, who are probably going to require a little more to keep them down in the beginning, then that little more gets stored and doesn't want to work its way out again.

I feel like it also makes people more confused/combative. My last facility used propofol almost exclusively for vent sedation with just PRN IVP pain meds; my current one addresses pain first (intubated patients are ALWAYS placed on fentanyl drips) and then adds sedation if the pain medicines alone don't address sedation, and precedex is used more often than propofol. I feel like 1/10 or less of my vented patients at my previous, propofol-heavy facility, followed commands and looked at me clearly while I was taking care of them. Most of them were either totally agitated and wanting to pull out their ETT or they were below RASS -2. Now, easily 1/3 or more of my vented patients look up and make eye contact with me when I'm in the room, and make no effort to pull their tubes. I can keep them at a 0 to -1 now much easier. I feel like that is almost unattainable with propofol.