# Propofol



## beantown native (Nov 5, 2012)

I am looking for someone who carries Propofol on their trucks. I am starting a new job and this EMS director has it on the trucks. Anyone using it ? Work well ?


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## TransportJockey (Nov 5, 2012)

Medics i know in Presidio Texas carry it along with a ton of other drugs. They all like it for continued sedation after ketamine or other rsi


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## lightsandsirens5 (Nov 5, 2012)

Continued sedation? Wow. Do they actually hang propofol drips? That would be amazing!


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## TransportJockey (Nov 5, 2012)

lightsandsirens5 said:


> Continued sedation? Wow. Do they actually hang propofol drips? That would be amazing!



Yep they do. They're ten minutes to the airport to wait for fixed wing air or hour and a half to the nearest hospital


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## Veneficus (Nov 5, 2012)

I don't work on a truck...

But I am very fond of using propofol, I think it works great.


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## rmabrey (Nov 5, 2012)

There was a very recent time where it was considered for our shop. Medical director approved it, but the pharmacy board would not. Then someone got the bright Idea to just order Etomidate straight from the manufacturer


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## lightsandsirens5 (Nov 5, 2012)

TransportJockey said:


> Yep they do. They're ten minutes to the airport to wait for fixed wing air or hour and a half to the nearest hospital



Lol! Do they carry a couple gallon jugs of the stuff? 

That's awesome though.


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## usalsfyre (Nov 5, 2012)

Fair amount if experience with it. It will be in our next update for CCT medics to initiate post-intubation, but not for initial induction.


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## 46Young (Nov 5, 2012)

Veneficus said:


> I don't work on a truck...
> 
> But I am very fond of using propofol, I think it works great.



We routinely used it with vented/sedated CCT's with standing orders for titration, of course, for when we need to play the hypotension/arousal yo-yo game. Great addition for any department with medium to long txp times, for sure.


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## FLdoc2011 (Nov 5, 2012)

lightsandsirens5 said:


> Continued sedation? Wow. Do they actually hang propofol drips? That would be amazing!



It's our go-to drip for ICU sedation.


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## NomadicMedic (Nov 5, 2012)

Not a great med for sedation when there is a lot of hubbub. I hear its great in the ICU, doesn't work so well on a bumpy, loud truck.


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## Miss EMT (Nov 5, 2012)

I work in the ER. We use it post intubation. Works great on most patients but did not work well at all on our bath salt patients.


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## usalsfyre (Nov 5, 2012)

n7lxi said:


> Not a great med for sedation when there is a lot of hubbub. I hear its great in the ICU, doesn't work so well on a bumpy, loud truck.


As long as the patient is tanked up it works well, the problem is usually a slightly hypovolemic patient who has the dose increased for the additional stimuli.


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## CANMAN (Nov 5, 2012)

n7lxi said:


> Not a great med for sedation when there is a lot of hubbub. I hear its great in the ICU, doesn't work so well on a bumpy, loud truck.



Titration to appropriate doses, while also maintaining good MAPs will achieve adequate sedation. Often I think people ginger their steps in titration, and that goes for most meds. 

Used on a ground unit doing hour plus intubated and vented patients without to many issues. Upon arrival at bedside pt. would get a bolus, then appropriate weight based drip, additional bolus dosages or other bolus sedative if needed.


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## NomadicMedic (Nov 5, 2012)

Perhaps, in my limited experience with it, my patients weren't appropriately preloaded...


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## 18G (Nov 8, 2012)

I've used it pretty frequently and observed good results inter-facility. Sometimes additional sedatives are required. In the intubated patient, adding fentanyl and addressing pain while bumping down the road is a better strategy than adding lorazepam or midazolam on top. Just my experience. 

Overall, I really like propofol.


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## RocketMedic (Nov 9, 2012)

Presidio's a crazy little service with an insane patient load. Those guys are very, very intelligent.


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## Farmer2DO (Nov 13, 2012)

18G said:


> I've used it pretty frequently and observed good results inter-facility. Sometimes additional sedatives are required. In the intubated patient, adding fentanyl and addressing pain while bumping down the road is a better strategy than adding lorazepam or midazolam on top. Just my experience.
> 
> Overall, I really like propofol.



I agree.  I use it a lot on IFTs.  I make sure the patient is adqequately volume resuscitated (so many from the small community hospitals are not) and often add an opiate to it, either morphine boluses or a fentanyl drip.  If they get really agitated, I'll midazolam boluses as needed.  

In my 911 service area, we're never more than 10 minutes from a hospital, so there's really no need for it there.


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## Veneficus (Nov 13, 2012)

Farmer2DO said:


> I agree.  I use it a lot on IFTs.  I make sure the patient is adqequately volume resuscitated (so many from the small community hospitals are not) and often add an opiate to it, either morphine boluses or a fentanyl drip.  If they get really agitated, I'll midazolam boluses as needed.
> 
> In my 911 service area, we're never more than 10 minutes from a hospital, so there's really no need for it there.



one day...

medical directors will figure out you do not need to make a cocktail with propofol, all you have to do is up the dose.


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## Farmer2DO (Nov 13, 2012)

Veneficus said:


> one day...
> 
> medical directors will figure out you do not need to make a cocktail with propofol, all you have to do is up the dose.



Sure, if they can tolerate it, hemodynamically.  

I know we've had this discussion before.  As a paramedic with extensive critical care transport experience, my opinion is that an opiate provides better analgesia than high dose propofol.  Using 2 agents means you can use less of each agent, thus limiting the side effects.

That's my experience, and it works quite well, bouncing down the road.


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## EMT B (Nov 13, 2012)

i may just be bls, but most of the time in my service area it is ALS assist--why do you need to worry about hypovolemia with this drug?


EDIT:

i apologize for my ignorance


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## Veneficus (Nov 13, 2012)

EMT B said:


> i may just be bls, but most of the time in my service area it is ALS assist--why do you need to worry about hypovolemia with this drug?
> 
> 
> EDIT:
> ...



there are 2 doses, the sedation dose (low dose) and the anesthetic dose (high dose) the anesthetic dose can cause hypotension.

Usually mitigared by saline.

You can use the anesthetic dose as an IV anesthetic by itself without another agent.


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## usalsfyre (Nov 13, 2012)

EMT B said:


> i may just be bls, but most of the time in my service area it is ALS assist--why do you need to worry about hypovolemia with this drug?
> 
> 
> EDIT:
> ...



Propofol is generally a CCT level drug. 

Hypovolemia is a concern because one of the actions of propofol is vasodilation and reduced inotropy. If you don't have the volume to make up for dialting vessels and a heart that isn't squeezing as hard you can get hypotensive quickly.


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## FLdoc2011 (Nov 13, 2012)

What Ven said.   The Anesthesia guys are the ones that mostly use bolus propofol during induction.  The few times I've had to push it in the ICU (ex: for intubation and nothing else was available)  I did see some transient hypotension that resolved with fluid.   Certainly something to keep an eye on and not usually a problem with maintenance doses for continued sedation.


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## polisciaggie (Nov 13, 2012)

We carry it but only for patients that we transfer out of our ER on vents.  It works very well from what I have seen.


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## Speedylifsavr (Nov 14, 2012)

We carry it also for RSI. We administer 2mg per kg IV push followed by anectine 1mg per kg. We can follow up with 25 mg IVP and repeat that if necessary for continued sedation.


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## EMT B (Nov 14, 2012)

I just learned in my Forensics course at school in our drugs and tox unit that Michael Jackson died due to an OD on propofol. Was it the propofol itself, or the fact that there was also Ativan, Versed, Valium, lidocane and ephedrine in his body? Which brings up my next point...wouldn't epedrine have been counterproductive as a sleep aid?


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## BF2BC EMT (Nov 14, 2012)

EMT B said:


> I just learned in my Forensics course at school in our drugs and tox unit that Michael Jackson died due to an OD on propofol. Was it the propofol itself, or the fact that there was also Ativan, Versed, Valium, lidocane and ephedrine in his body? Which brings up my next point...wouldn't epedrine have been counterproductive as a sleep aid?



You JUST learned that's how he died?


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## usalsfyre (Nov 14, 2012)

Speedylifsavr said:


> We can follow up with 25 mg IVP and repeat that if necessary for continued sedation.


:blink:

Why not just start an infusion?!?


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## Farmer2DO (Nov 14, 2012)

usalsfyre said:


> :blink:
> 
> Why not just start an infusion?!?



Agreed, because that 25 mg propofol will last for about.....2 minutes.  Unless the patient weighs 50 lbs.  Then it'll last for about 6.


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## EMT B (Nov 14, 2012)

BF2BC EMT said:


> You JUST learned that's how he died?



ok well i knew it was propofol but i didn't know what the hell that was until reading this. . .and then just made the connection I should say...so is my question going to get answered, cause that wasn't really the point...


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## Speedylifsavr (Nov 14, 2012)

usalsfyre said:


> :blink:
> 
> Why not just start an infusion?!?



I'd love too! But hay..... It's my protocol and I have to follow it.


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## lightsandsirens5 (Nov 14, 2012)

While I am all for following protocol in order to stay out of prison, one day I'm going to hunt down the dude that came up with EMS protocols and the dude that coined the saying "it's protocol".....do something terrible. What, I have not yet decided.


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## jwk (Nov 15, 2012)

Veneficus said:


> You can use the anesthetic dose as an IV anesthetic by itself without another agent.



Propofol is a sedative/hypnotic agent that was developed for and primarily used for induction of general anesthesia.  Using it for ICU and procedural sedation was not really among it's initial indications.  However, describing it as an anesthetic agent is not really correct.  Propofol in and of itself has no analgesic properties.  You can depress consciousness enough that a patient may not respond to a painful stimuli (all the way to a flat EEG) but that's not the same thing.  I can assure you we do not and could not do surgery with propofol alone.


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## wannabeHFD (Nov 15, 2012)

I just want to say, my dad was given it for a procedure, and it was hilarious when he woke up.


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## rwik123 (Nov 15, 2012)

He was probably given another agent that produced this effect. Propofol doesn't produce the delirium that I think your referring to.


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