Propofol use not quite ready for prime-time. The info below is informational only until we have a Nursing Protocol for the use of propofol that is ED specific in place.
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Propofol has been approved for use in the ED for post-intubation sedation and may be ordered in IBEX by all attendings.
It should not be used as a continuous infusion for patients under age 18.
The starting dose is 5 mcg/kg/min, titrated upwards by 5 mcg/kg/min every 10 minutes until desired sedation level is reached.
An infusion chart is available on the EHCED site:
http://www.ehced.org/Drips/propofol.pdfI spoke with Robert Asselta today and he reported that all nurses should be able to hang and deliver propofol as a standard infusion, effective immediately.
For now, only use Propofol on intubated patients being monitored with continuous ETCO2 and automated, repeating blood pressure checks. Although propofol offers minimal if any benefit in most intubated patients when compared to midazolam, we must demonstrate a safe record of use before we petition the P&T committee to allow us to use it for RSI and procedural sedation, where it does offer significant advantages in certain situations. Propofol's rapid offset of action does have particular utility in the patient intubated for CNS lesions, as the patient's neurological status can be quickly re-evaluated after discontinuing the infusion.
Propofol causes respiratory depression, which is not an issue in an intubated patient, and hypotension, which can be. Be mindful of hypotension in susceptible patients.
I have pasted the summary I sent out months ago below for further information.
Thanks to all the MSSM attendings for suffering through the preliminary steps, thanks to Haru and Ruben for their efforts. Looking forward to seeing the milk-colored infusions.
reuben
* Propofol is a potent sedative-hypnotic that is structurally
different than but behaves similarly to the barbiturate class. It
produces dose-related sedation and amnesia, up to and including deep
sedation, in which case patients are unresponsive to painful stimuli
and may be apneic.
* Propofol has become popular for use in emergency medicine because
of its unique pharmacokinetics. When given as a bolus, onset of
action is generally within 1 minute, and duration of action is
generally not longer than several minutes. Patients are generally
completely alert within 15 minutes.
* Propofol may be used as an infusion to maintain sedation in
intubated patients. The recommended starting dose is 5 micrograms /
kg / minute, to be titrated to effect every 10 minutes. Note that 5
mcg/kg/min is a very small dose. Propofol is particularly well-suited
for this purpose if following the patient's neurological exam is
important, as the effect wears off completely within 15 minutes of
holding the infusion.
* Propofol may be used to facilitate painful procedures. The
recommended dose is 1 mg/kg bolus, but experienced providers use
anywhere from .5 to 1.5 mg/kg as their starting doses. Repeat dosing,
usually at .5 mg/kg, must be provided quickly if needed, every 3
minutes at the longest, as the effect is so short-lived.
* Propofol is the most popular agent among anesthesiologists for RSI,
and may also be used to treat refractory delerium tremens and status
epilepticus. We can discuss these indications later as need and
interest warrant.
* Propofol is contraindicated in patients with egg or soy allergy, as
both of these ingredients are in the vehicle.
* Propofol causes pain at the injection site. This pain can be
reduced by adding lidocaine, .5 mg/kg, to the syringe. This is
routinely done in the OR and rarely done in the ED.
** Propofol routinely, reliably produces respiratory depression,
including apnea, as well hypotension. However, the clinical relevance
of these effects is greatly reduced by propofol's ultrashort duration
of action.
-When end-tidal capnography is utilized (and it should be, if
available), there is no benefit to withholding supplemental oxygen.
In a healthy adult, adequate preoxygenation allows for periods of
apnea much greater than is routinely encountered with bolus propofol,
without desaturation. My experience is that the bolus is delivered,
the patient becomes unconscious, stops breathing, and starts
breathing within about a minute, without the saturation moving from
100%.
- Hypotension is to some degree prevented by pretreatment with
fluids; in any case the drop in blood pressure is brief and rarely of
clinical significance. In patients where hypotension is a particular
concern, it can be abolished with phenylephrine 100 microgram boluses.
** Though propofol has been demonstrated to be safer than
alternatives many of us are more comfortable with ( e.g. fentanyl /
midazolam), those who use it must anticipate its side effects and be
prepared to support blood pressure and ventilation as needed.
