# Propofol



## Nitsud21 (Feb 1, 2015)

New here to emtlife and new medic. I had an intubated patient on propofol. We transport it but cannot titrate it at all if needed. My patient was starting to wake up on it and we kept the rate the same from the hospital we picked up from. Just wanted to see people opinion or experiences like this and how you handled it. Thanks!


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## NomadicMedic (Feb 1, 2015)

I was allowed to titrate it to effect. The does to maintain sedation is less in a quiet room, compared to a loud, bouncy ambulance. 

Not being able to titrate a running medication when conditions change is ludicrous. Could you call med control for titration orders?


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## Nitsud21 (Feb 1, 2015)

I tired to between fighting him to not pull at his tube and chest tube. They just had me leave it alone though. Pt was pretty much awake by time we rolled into ER.


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## CANMAN (Feb 1, 2015)

DEmedic said:


> I was allowed to titrate it to effect. The does to maintain sedation is less in a quiet room, compared to a loud, bouncy ambulance.
> 
> Not being able to titrate a running medication when conditions change is ludicrous. Could you call med control for titration orders?



Ludicrous and down right dangerous especially depending on your programs definition of "titrate", like not being able to titrate the medication to OFF if needed....
As DEmedic said depending on the environment, patient weight, additional sedatives on board etc will depend on what dosage you need to be effective. What dose was the patient running at, and what was his weight? While some programs do not let the providers bolus Propofol, most who are doing IFT allow titration while paying attention to your blood pressure. We can titrate up to 50mcg/kg/min right off the bat, and up to 100mcg/kg/min with a consult. Over 100mcg/kg/min is generally considered to be TIVA/Total IV Anesthesia.

You could always add in Fentanyl with the Propofol, they work well when combined. You have to be careful when using Versed and Propofol to achieve sedation as hypotension can sometimes be profound. 

Did the patient has on soft wrist restraints? Chest tube and intubated = wrist restraints......


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## specwisconsin (Feb 1, 2015)

If you can't titrate a medication you shouldn't be taking it. Sounds like you need to have a sit down with operations.


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## NomadicMedic (Feb 1, 2015)

How about a versed bolus? Or versed? Or maybe some versed?

Were you just a taxi that was transporting a sick patient? If you have no ability to fix this stuff,it's the same as putting him in the back of a minivan and driving him.  Hell, he'd been just as comfortable on the bus!

I mean, if I was tubed and FIGHTING with the medic that was doing the IFT, I'd make sure to come back for a chunk of him after discharge. (And if I died, I'd haunt him!)

Transport of a sedated patient needs standing orders for titration of sedation and pain management.  Do you have a CCT/ALS standing order package. If it's something outside your normal scope, either the doc writes transport orders that supersede your standing orders or you bring a nurse that can manage the patent. 

This is a pretty crappy experience for the patient.


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## Nitsud21 (Feb 1, 2015)

He was at 40mcg/kg/min weighing 72kg. I was considering versed but was quite concerned with that making him hypotensive. Glad I didn't since you said it can be profound. Believe me wrist restraint will be on if I run across this situation again!


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## CANMAN (Feb 1, 2015)

Yup if your protocol allows it soft wrist restraints for all intubated patients in my opinion. (This is also our protocol) An under sedated patient can quickly become a non sedated patient and pull a tube with the turn of a head. No reason not to restrain them for the transport environment, which as we have already established is rich with stimulus.

40mcg/kg/min is a fair dose, however you could stand to go up, and like I said add some Fentanyl. Propofol and Versed both work on GABA receptors, thus why you will see certain side effects such as hypotension potentiated.

Also keep in mind Propofol by itself does not provide any analgesia, which is why coupled with Fentanyl it works great.

If you had adequate blood pressure to work with, and the protocol/orders to be able to titrate, I would titrated to 50mcg/kg/min and given 1mcg/kg of Fentanyl, see where that puts you, and repeat the Fentanyl every 10 minutes or so. If that is not doing the job then maybe reconsult for additional orders to exceed 50mcg/kg/min on the drip and maybe add some Versed, while watching your B/P's.


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## WestMetroMedic (Feb 1, 2015)

Propofol is great in a surgical or ICU setting where noise levels are controlled, extraneous stimulus is mitigated and intubations always happen at chest level. In the EMS realm, propofol is generally a poor anesthetic choice and only achieves its desired effects as high doses. This is where experience and diplomacy come into play. We feel like we need to accomplish our transport because its what we do, "You call, we haul." That shouldn't exactly be the case. If we are going to be consummate professionals and define ourselves as "physician extenders who also happen to drive an ambulance," then we need to be able to advocate for our patients, not just take it because they are the doctors and nurses and we are the subservient Paramedics. 

Engaging the facility that is trying to transfer this patient in a way that explains the concerns that you have is the wisest option. Many folks don't realize how poor of a sedative propofol is in ER and EMS settings. They don't do our job, we shouldn't expect them to understand our nuances. Sharing that perhaps we could switch to an agent like vecuronium ketamine during this transfer "because I don't think that the patient's blood pressure will tolerate significant uptitration of propofol," or even "in order for me to accomplish this transport safely, I need you to give some wiggle room on sedation. I don't think that set dose propofol will suffice."

At the end of the day, we also work for a physician, and this transport is generally on their license, which means their derriere is the one hanging out in the wind. Engage your physician, and if it is your physician trying to send this patient down the road, once you pull out of the ED, dial up the receiving facility, because ultimately, the first rule of plumbing rules; poop flows downhill. They will have to deal with this patient, how would they like the patient to arrive?


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## CANMAN (Feb 1, 2015)

WestMetroMedic said:


> Propofol is great in a surgical or ICU setting where noise levels are controlled, extraneous stimulus is mitigated and intubations always happen at chest level. In the EMS realm, propofol is generally a poor anesthetic choice and only achieves its desired effects as high doses. This is where experience and diplomacy come into play. We feel like we need to accomplish our transport because its what we do, "You call, we haul." That shouldn't exactly be the case. If we are going to be consummate professionals and define ourselves as "physician extenders who also happen to drive an ambulance," then we need to be able to advocate for our patients, not just take it because they are the doctors and nurses and we are the subservient Paramedics.
> 
> Engaging the facility that is trying to transfer this patient in a way that explains the concerns that you have is the wisest option. Many folks don't realize how poor of a sedative propofol is in ER and EMS settings. They don't do our job, we shouldn't expect them to understand our nuances. Sharing that perhaps we could switch to an agent like vecuronium ketamine during this transfer "because I don't think that the patient's blood pressure will tolerate significant uptitration of propofol," or even "in order for me to accomplish this transport safely, I need you to give some wiggle room on sedation. I don't think that set dose propofol will suffice."
> 
> At the end of the day, we also work for a physician, and this transport is generally on their license, which means their derriere is the one hanging out in the wind. Engage your physician, and if it is your physician trying to send this patient down the road, once you pull out of the ED, dial up the receiving facility, because ultimately, the first rule of plumbing rules; poop flows downhill. They will have to deal with this patient, how would they like the patient to arrive?




Your still routinely paralyzing patients for transport....?  In 90 to 95% of the intubated patients we transfer in my program we are able to safely and effectively managed their sedation, and pain, without the need to give NMB agents. Not saying that those situations don't exist, however should not be the standard of practice in my opinion.

It seems like we are dealing with an IFT here and a provider that obviously does not do this frequently. With that being said I would be concerned about paralyzing someone who is intubated right off the bat, without knowing about potential acidosis, minute volumes, and such..... That's how provider's kill patients on mechanical ventilation and never understand what happened when the patient codes.


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## WestMetroMedic (Feb 1, 2015)

CANMAN said:


> Your still routinely paralyzing patients for transport....?  In 90 to 95% of the intubated patients we transfer in my program we are able to safely and effectively managed their sedation, and pain, without the need to give NMB agents. Not saying that those situations don't exist, however should not be the standard of practice in my opinion.
> 
> It seems like we are dealing with an IFT here and a provider that obviously does not do this frequently. With that being said I would be concerned about paralyzing someone who is intubated right off the bat, without knowing about potential acidosis, minute volumes, and such..... That's how provider's kill patients on mechanical ventilation and never understand what happened when the patient codes.



Touche. I do agree with your sentiment completely and retract the bit about Vec, but i still must advocate for Ketamine. It's the primary anesthetic in most of the world, generally adverse reaction free, and gives you some wiggle room to augment with benzos (which also prevent re-emergence). It is easy to switch propofol patients to ketamine and quickly titrate at almost the same rapid onset as propofol.  

I also don't do CCT or IFT anymore, i've been out of that game for awhile now and am admittedly rusty. Most of my paramedicatin' is Community Paramedicatin' and involves keeping heart failure people out of the hospital, but since this is the internet, I HAVE TOTAL AUTHORITY AND CONFIDENCE!


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## CANMAN (Feb 1, 2015)

Echo and agree with the Ketamine. It's a great agent, gives a good vasoconstriction so the increase in B/P for a borderline patient can be beneficial. Extremely under-utilized in alot of transport programs. Great points!


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## Carlos Danger (Feb 1, 2015)

These are spectacularly craptastic situations. They are dangerous to the patient and unfair to everyone involved. I would have a serious discussion with your medical director about developing protocols for these situations, or referring them to a CCT program that does.

A few thoughts:

Restraints are helpful and should probably be used (or at least readily available) anytime you are transporting an intubated patient who is not paralyzed. But they don't solve the problem of inadequate sedation.

Propofol is an excellent drug for sedation in these patients; you just have to use an adequate dose, and it helps a lot if you have narcotic on board. 

If propofol is the only thing you are using for sedation, it _will_ take significantly more during transport than it did in the hospital. 50 mcg/kg/min is a good place to _start_, but if you have no narcs or benzos on board, I'd expect to need somewhere between 80-120 to keep the patient quiet and still. I understand that this was not an option for you, though.

Versed probably would have worked fine. It would NOT have caused hypotension if the patient was as agitated as you describe.

Fentanyl would have been a better option than versed for various reasons. Give 50mcg boluses every 3 minutes until they are quiet. For a 72 kg patient you probably only need 100mcg total, unless they are opioid tolerant, in which case you'll need a higher dose.

Some ketamine with the propofol is a good option if BP is an issue. Otherwise fentanyl is probably better.

Probably the best way to manage these patients is to get a good dose of morphine or dilaudid on board, and then titrate the propofol on top of the narcotic. This is because propofol has a much faster onset and offset than narcotics, so it's easier to titrate the dose of it. 

Lastly, I am of the firm belief that, baring a good reason not to (and I can think of very few reasons not to), all intubated patients should be paralyzed for transport. It simply makes things easier and safer.


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## CANMAN (Feb 1, 2015)

Remi said:


> These are spectacularly craptastic situations. They are dangerous to the patient and unfair to everyone involved. I would have a serious discussion with your medical director about developing protocols for these situations, or referring them to a CCT program that does.
> 
> A few thoughts:
> 
> ...



- Don't think anyone said restraints solve the problem of inadequate sedation....

- Your last point, why are your beliefs such? If you can adequately get a patient sedated and manage their pain without it, why do it? There have been very few times in my career a patient couldn't be managed with such and NEEDED to be paralyzed for the transport. Situations like a patient on APRV/Bi-Level, ECMO, etc. 98% of the patient's in a CCT environment certainly do not need paralytics just to be transported, and "makes things easier and safer" is bull hockey. I go back to my point of patient safety = wrist restraints...... That is a very old school way of thinking and most, if not all of the tertiary care centers in my area have gone away from this practice, not only in transport, but also in the ICU's. We don't paralyze patients for provider convenience. I think for ALOT of services who may not being transferring super high acuity on a regular basis your asking them to monitor for alot of significant changes, which may be harder to pickup on, just because that patient is now paralyzed.


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## Carlos Danger (Feb 1, 2015)

Keeping patients paralyzed for days on end in the ICU = many known negative effects.

Giving a single dose of NMB for a 30 minute transport = not a single downside.



CANMAN said:


> If you can adequately get a patient sedated and manage their pain without it, why do it?



People talk a lot about how you don't "need" paralysis in transport. No one gives a good reason why that is a better approach, though.

I do agree, you don't usually "need" it. The problem is that until you get into the transport, it is impossible to predict when it would have been a good idea. That, and there are virtually zero downsides to using NMB's - they are very safe, predictable, "clean" drugs with very limited physiologic effects. You can't say that about larger doses of propofol, benzos, or opioid. If there is an issue with patient exam at the receiving hospital, NMB is less of a confounder than sedating medications are, because the degree of remaining NMB effect can very easily be objectively measured, and, if needed, quickly reversed, with no negative physiologic effects. Again....not true of large doses of propofol, benzo, or opioid.

To be honest, I think quite often - and I'm _not_ saying this is necessarily the case with you, just in general - this is just ego talking. The whole "I don't need no stinkin' paralytic - I'm too skilled to need that crutch" attitude.

The bottom line is, the idea that it's somehow better for patients to avoid NMB in transport is one of the many EMS myths out there. If there were any downsides to NMB in transport, then I'd be all for avoiding them. But there aren't, so I'm not.

Dilaudid + propofol + vec = comfortable, still patient = easy, safe transport.


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## CANMAN (Feb 1, 2015)

Remi said:


> Keeping patients paralyzed for days on end in the ICU = many known negative effects.
> 
> Giving a single dose of NMB for a 30 minute transport = not a single downside.
> 
> ...



Not a single downside huh...? So you want the average mom and pop ambulance service, who does a few IFT's a month, to go paralyzing every intubated asthmatic or DKA patient they come in contact with because theres not a single downsided? Taking an acidotic patients respiratory effort away meh whats the worst that can happen...?

Has nothing to do with ego and thinking "i don't need a paralytic" but has everything to with not giving a medication that is not indicated for upwards of 98 percent of the transfers that occur on a daily basis.

Again what "safety" concerns are you worried about with a properly secured, sedated, and wrist restrained intubated patient...?


I am not discounting that you have a great deal of clinical knowledge, and I am aware of your current practice setting. However I disagree with your post and clinical judgement and have seen providers kill patients by "paralyzing everyone", lacking in their knowledge base and lacking in their management skills. I think its a board statement and certainly not the practice in any of the HEMS programs, tertiary care facilities I transport to, or the OR, other then induction, in my area. My anesthesia & critical care trained medical director would also agree.


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## CANMAN (Feb 1, 2015)

I also realize and appreciate that every clinician will have a different approach based off their knowledge, experience, setting, scope, and protocols. So with that being said I want the thread to get back on track, however collaboratively I think all have answered the OPs original question and provided the feedback.


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## systemet (Feb 1, 2015)

There's some great points here.

I think the major drawback to paralysing for transport is that you're taking a patient with (hopefully), a functional sedation / analgesia package, and putting them in a new environment with a lot of extra stimulation and stressors, and removing a lot of your physical examination tools for assessing whether this package is still suitable / effective.

Obviously, each area has its protocols and guidelines, but it seems that the best approach would be to engage in a discussion with the sending facility, and develop a plan for any agitation / tachycardia / asynchrony, that might arise during transport.  While I don't have a ton of experience with propofol, I can attest to the fact that it often needs to be titrated up during transport, at which point the vasoactive effects manifest, and may result in having to titrate up pressors, which can result in a dangerous cycle of titrating up and down multiple agents.

I like the option of fentanyl, either as aliquots for a short duration transport, or as a bolus followed by an infusion.  I think ketamine's ok, but often see it used in tandem with fentanyl. I'm not too keen on the midazolam.  While I agree that agitated patients have a lot of sympathetic drive and tend not to tank as much, the combination of benzos/propofol seems like it offers an opportunity for some spectacular badness.

But I think you two may have more experience in this realm than me.

Edit:challenges with apostrophes


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## Carlos Danger (Feb 1, 2015)

CANMAN said:


> Not a single downside huh...? So you want the average mom and pop ambulance service, who does a few IFT's a month,


 No, I don't want mom and pop ambulance services who only do a few IFT's a month to do CCT's at all. If you aren't qualified you aren't qualified. That has nothing to do with  the discussion at hand.



CANMAN said:


> to go paralyzing every intubated asthmatic or DKA patient they come in contact with because theres not a single downsided? Taking an acidotic patients respiratory effort away meh whats the worst that can happen...?



I'm not sure what you are saying here. Are you suggesting that an intubated patient can maintain a higher minute volume with spontaneous effort than without? That doesn't make much sense. It isn't like a well sedated patient is breathing adequately to avoid respiratory acidosis - they need support, hence the ETT and ventilator. 

Once a severely acidemic patient is intubated, you are committed to matching their metabolic demands, whether they are paralyzed or not. And you are almost certainly able to reach a higher minute volume with relaxation than without....in fact this is one of few remaining generally accepted indications for NMB in the ICU. If you don't use NMB, you are probably going to need so much sedation that you have negated any advantage that you had by avoiding NMB.



CANMAN said:


> Again what "safety" concerns are you worried about with a properly secured, sedated, and wrist restrained intubated patient...?



Here are some of the things that I've seen happen during transfers of intubated patients who just moments before, appeared adequately sedated:

Reaching for things that you really don't want them to grab, like the ETT, cordis, or helicopter door handle
Injuring themselves against restraints
Breaking restraints
Coughing and bucking
Moving their head enough to change the position of the ETT
Requiring large boluses of sedatives and increases in rate in order to calm them down, causing hemodynamic instability

I am still waiting for someone to articulate a reason why NMB should be avoided.


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## MonkeyArrow (Feb 1, 2015)

Remi said:


> I am still waiting for someone to articulate a reason why NMB should be avoided.


Do you start an IV on every patient you treat, too? I mean, you don't know when a patient could suddenly bottom out and code on you and its good to have vascular access and not need it, then need it and not have it. Nevermind the fact that you are lacking medical necessity. [Obviously, I'm referring to IFTs where you need to take little old Mrs. Smith to her regularly scheduled doctor's appt., not a critical pt.] This seems like more of a case of a procedure looking for an indication rather than an indicated procedure (if that makes any sense).


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## Tigger (Feb 2, 2015)

MonkeyArrow said:


> Do you start an IV on every patient you treat, too? I mean, you don't know when a patient could suddenly bottom out and code on you and its good to have vascular access and not need it, then need it and not have it. Nevermind the fact that you are lacking medical necessity. [Obviously, I'm referring to IFTs where you need to take little old Mrs. Smith to her regularly scheduled doctor's appt., not a critical pt.] This seems like more of a case of a procedure looking for an indication rather than an indicated procedure (if that makes any sense).


Sweet apples to orange comparison.


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## CANMAN (Feb 2, 2015)

Again Remi, I am not challenging your clinical knowledge, experience, or training. I will be the first to to say I believe you are far more educated then I am, I respect your knowledge, and think you bring a lot to the forum. I just completely disagree on this particular topic. We both have significant clinical experience in this arena I believe, but at the end of the day I just have a difference in opinion. Maybe I didn't make my points clear, and that is my fault. I am saying we have some very high speed provider's on the forum, however not every ambulance company or Paramedic doing intubated inter facility transports are of that caliber, and we can't control that. Those services, and or provider's light on the experience and knowledge required to transport such a patient will sadly, but ALWAYS exist. With that being said I think pairing that type of company/provider up with a described type of patient, coupled with a lack of understating of minute ventilation, acidosis, etc and then stating all of them should be paralyzed, your effectively counting on them to meet those patient demands that they don't even have a clear understanding of, and I think your asking for trouble. And if you have already acknowledged "it's not needed all the time" then why do it in the first place? It literally takes me less than 30 seconds to draw up and administer Vec if something gets out of hand. The things below just seem ridiculous to me, almost grasping at straws to prove a point.


Reaching for things that you really don't want them to grab, like the ETT, cordis, or helicopter door handle (Ummm wrist restraints, problem solved, and what type of airframe are you flying in that the patient can reach the door handle while intubated?)
Injuring themselves against restraints (Soft wrist restraint injuries, never seen such a thing with sedation on board, we check for skin breakdown and pulse, motor, sensory Q15 minutes as required)
Breaking restraints (Are we transporting involuntary psych patients on PCP, or an intubated patient with some sedation on board? Never in my career have I had an intubated patient on propofol or other sedative, that active, that they physically broke a restraint)
Like I said your practice and mine differ greatly in this topic, and I manage to transport hundreds of inter facility transports without any of the above stated issues. I am just going to agree to disagree, different programs and clinicians have different approaches, and like I said acknowledge your advanced education. Thanks for the intelligent debate, I am checking out.
Cheers,


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## Carlos Danger (Feb 2, 2015)

MonkeyArrow said:


> Do you start an IV on every patient you treat, too? I mean, you don't know when a patient could suddenly bottom out and code on you and its good to have vascular access and not need it, then need it and not have it. Nevermind the fact that you are lacking medical necessity. [Obviously, I'm referring to IFTs where you need to take little old Mrs. Smith to her regularly scheduled doctor's appt., not a critical pt.] This seems like more of a case of a procedure looking for an indication rather than an indicated procedure (if that makes any sense).



Sorry, but that is just a silly comparison.




CANMAN said:


> Again Remi, I am not challenging your clinical knowledge, experience, or training. I will be the first to to say I believe you are far more educated then I am, I respect your knowledge, and think you bring a lot to the forum. I just completely disagree on this particular topic. We both have significant clinical experience in this arena I believe, but at the end of the day I just have a difference in opinion. Maybe I didn't make my points clear, and that is my fault. I am saying we have some very high speed provider's on the forum, however not every ambulance company or Paramedic doing intubated inter facility transports are of that caliber, and we can't control that. Those services, and or provider's light on the experience and knowledge required to transport such a patient will sadly, but ALWAYS exist. With that being said I think pairing that type of company/provider up with a described type of patient, coupled with a lack of understating of minute ventilation, acidosis, etc and then stating all of them should be paralyzed, your effectively counting on them to meet those patient demands that they don't even have a clear understanding of, and I think your asking for trouble. And if you have already acknowledged "it's not needed all the time" then why do it in the first place? It literally takes me less than 30 seconds to draw up and administer Vec if something gets out of hand. *The things below just seem ridiculous to me, almost grasping at straws to prove a point*.



Ridiculous? Grasping at straws? Remember that just because you haven't seen something doesn't mean it never happens. I cited real examples of things that I have actually seen happen. Not every day of course, but complications during transport of ventilated patients are actually quite common - something like 20% of transports in one study, most of which were related to the hemodynamic consequences of over-sedation or asynchrony with the ventilator. On the other hand, I still have not seen you cite a single example of why NMB should be avoided.

Look, I'm not saying that you anyone else is _wrong_ for not using paralytic. I realize that a lot of smart people - some much smarter than me - agree 100% with you and would tell me that I'm FOS. That's fine. Again, I've never seen those people come up with a _reason_ why I'm FOS, but we can of course disagree.

The thing is - the reason I felt it was important to mention NMB to the OP - is that I think you have it backwards with the experience thing. If you do a lot of CCT and are really comfortable with vents and balancing sedatives and analgesics against hemodynamics, and consequently have made it part of your practice to avoid NMB, then good for you. Nothing wrong with it at all.

However, for someone who is not experienced with ventilators or using the associated drugs (whether they should even be doing the transport in the first place is another topic altogether), relaxation makes the whole thing safer and easier. By any measure. NMB's are safe and easier to use, with far fewer side effects than large doses of sedatives or analgesics. And the OP's scenario is a perfect example.....if he had just given some vec, the transport would have been entirely different. I rest my case.


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## triemal04 (Feb 2, 2015)

Remi said:


> Here are some of the things that I've seen happen during transfers of intubated patients who just moments before, appeared adequately sedated:
> 
> 1.  Reaching for things that you really don't want them to grab, like the ETT, cordis, or helicopter door handle
> 2.  Injuring themselves against restraints
> ...


(numbers added to make it simpler)

There isn't anything inherently wrong or unsafe with the use of longterm paralytics, or their use during a transport and not in a hospital; it's just that the majority of the time they really aren't needed.  Sometimes they certainly are, depending on the specific disease process/injury or type of transport and mode of ventilation, and having a lower threshold for their use while in flight is certainly appropriate.  But indiscriminently giving them "just because" is wrong.  Just because something is not explicitly harmful in no way means that it is appropriate to blatantly give it/do it; like anything, if there is no need for it, why do it?  

Now, you have already made it clear that you'll just look at that statement as a case of ego talking, but it's not; it's just a statement of fact- most patient's do not require a paralaytic, but some do.

While giving a paralytic may make the provider feel more secure and calm, if the patient was agitated and aware enough to be causing a problem the possibility of them having some memory of the episode goes up.  Despite what some people here think, the times when that is acceptable are few and far between.  Not to mention that it's a bit hypocritical to, on the one hand, say that providers aren't capable of appropriately sedating patients who aren't paralyzed (and thus will have many more indicators of inadequate sedation) and yet also say that they should give a med that will decrease the liklehood of noticing inadequate sedation. 

As far as your reasons for using a long-term paralytic: 

1.  Soft restraints make a great solution and give you plenty of time to increase your sedation.
2,3,4,5,6.  Those are all a function of not having the patient at an appropriate level of sedation, either because it was never reached to begin with, or not maintained correctly, as well as not being prepared to treat the patient. 
3.  You really want people to believe that the patient went from completely unresponsive to awake enough that they broke a restraint and it was so fast you didn't have time to re-sedate them or paralyze them?  I'm sorry, the concerns that raises have nothing to do with paralytics.
5.  Improperly secured ET tube.

All due respect, but to have you, as a provider of anesthesia sit here and say that paralytics are always required because you can't reach an appropriate level of sedation is mind boggling.


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## triemal04 (Feb 2, 2015)

Tigger said:


> Sweet apples to orange comparison.


It's actually not the world's worst comparison.

Basically, remi is saying that you should paralyze intubated patient's that don't currently need it because at some point they could become a problem.

Monkeyarrow is saying that you should start an IV on all patients because at some point they might need it.

Obviously, the odds of an intubated patient requiring a long-term paralytic for at least one dose are much higher than the average patient arresting, but to be honest the comparison is valid.


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## Carlos Danger (Feb 2, 2015)

triemal04 said:


> All due respect, but to have you, as a provider of anesthesia sit here and say that* paralytics are always required* because you can't reach an appropriate level of sedation is mind boggling.



Just as you have in previous discussions, you are mischaracterizing what I wrote.

I never said that paralytics are _always_ _required_. What I said they have zero downsides, are more predictable and have fewer side effects than the doses of sedation that may be required to keep a patient still in lieu of NMB, and that many who do these transports don't have the experience with ventilators and sedatives that is required to keep a patient comfortable and safe with sedation alone. And that therefore, I think using them routinely is _a good idea_.

Big difference between "a good idea" and "always required".





triemal04 said:


> It's actually not the world's worst comparison.
> 
> Basically, remi is saying that you should paralyze intubated patient's that don't currently need it because at some point they could become a problem.
> 
> ...



Uh, no.

Drawing a logical equivalent between routinely starting an IV in a patient with no acute medical problem vs. using NMB in an intubated patient during transport, is like saying that wearing a kevlar vest and helmet while sleeping in your bed at home "just in case" is the same as wearing a helmet when riding a motorcycle.

You have to really stretch far to get that one to work.


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## triemal04 (Feb 2, 2015)

Remi said:


> Just as you have in previous discussions, you are mischaracterizing what I wrote.
> 
> I never said that paralytics are _always_ _required_. What I said they have zero downsides, are more predictable and have fewer side effects than the doses of sedation that may be required to keep a patient still in lieu of NMB, and that many who do these transports don't have the experience with ventilators and sedatives that is required to keep a patient comfortable and safe with sedation alone. And that therefore, I think using them routinely is _a good idea_.
> 
> Big difference between "a good idea" and "always required".


Take a breath for a minute.  I'm not mischaracterizing anything.  What you said was this:


Remi said:


> *Lastly, I am of the firm belief that, baring a good reason not to (and I can think of very few reasons not to), all intubated patients should be paralyzed for transport.* It simply makes things easier and safer.


edit:  your stance seems very clear here and in the rest of your postings.  

Personally, lack a real need is a good reason for me to not do something.  Others obviously have different opinions.

Would you like to address any of the points I brought up in my first response to this thread?  Because, while I'm happy to discuss this with you, I think those should be put to bed before we move on to monkeyarrow's unfortunately legitatmite comparison.


----------



## MonkeyArrow (Feb 2, 2015)

Remi said:


> Uh, no.
> 
> Drawing a logical equivalent between routinely starting an IV in a patient with no acute medical problem vs. using NMB in an intubated patient during transport, is like saying that wearing a kevlar vest and helmet while sleeping in your bed at home "just in case" is the same as wearing a helmet when riding a motorcycle.
> 
> You have to really stretch far to get that one to work.


Do you bill for the administration of NMB during transport? Just as we had a thread here earlier on starting IVs on IFT transfers in the ED ambulance bay and billing for it to charge medicaid and the whole medical necessity thing, is the routine use of NMB clinically justified? Ascertained by your response to my IV hypothetical, I'm assuming that you don't start an IV on every non-acutely injured/ill pt. that you treat. IV insertion is an invasive procedure that carries a risk of complication just like any other procedure or medication administration does (albeit, a very low risk almost to the point of it being negligible). Why then wouldn't you start an IV on every patient since you could have missed a zebra on your seemingly non-acute patient. Their pressure could drop or their slip and fall could have ruptured an AAA or they could have burst their spleen, all requiring IV access. Since the risk is so low, given that the risk of starting an IV is lower than that of administering NMB routinely and the utility of having an IV is well documented, why don't you start an IV in every pt.? The same line of thinking you use for NMB admin is covered for IV insertion. 

NMBs should be used because they're safe and they can potentially increase the safety of the transport.
IVs should be started on everyone because they're even safer than paralytic administration and carry an equal, if not greater utility for being used at sometime throughout the care that the patient receives.

PS Wearing kevlar and a helmet while sleeping may be a stretch but is having a gun next to your pillow also a stretch?

PPS Sorry triemal04, I only saw your post about my comparison after I had finished typing this longwinded response up. I'l post it but feel free to ignore it until you finish debating your points with remi.


----------



## zzyzx (Feb 2, 2015)

To the original poster...are you sure that your protocols allowed you to transport propofol? Are you familiar with propofol at all?
Regardless, you really should have refused. So you are not allowed to adjust the medication at all? What if the patient had become really hypotensive, as often happens with that medication?
This should have been a CCT transport.
I hope this doesn't come across as me being too critical of you. I think you were placed in a bad position by someone at the hospital, and perhaps because they were an MD or a charge nurse, you thought they knew better.


----------



## Carlos Danger (Feb 3, 2015)

triemal04 said:


> Take a breath for a minute.  I'm not mischaracterizing anything.  What you said was this:
> 
> 
> 
> ...




You absolutely _are_ mischaracterizing my position; you just did it again by quoting the statement of mine above - in isolation, without the context of the rest of the discussion.

What you are doing is attempting to create a straw man ("every intubated patient must always be paralyzed for every transport") that you can argue against and prove wrong much more easily than you can argue against what I actually meant, which was, "NMB during transport of an intubated patient _is generally a good idea, especially if you don't do these transports much_." You've done the same thing in other discussions in an attempt to prove someone wrong out of hand, rather than discussing the issue.

If you had actually paid attention to the overall point I was trying to communicate, rather than just cherrypick specific items that alone make it sound as though I meant something I didn't, you would also have seen this statement:



Remi said:


> I do agree, you don't usually "need" it.



And this one:



Remi said:


> I'm not saying that you anyone else is _wrong_ for not using paralytic.



And this one:



Remi said:


> we can of course disagree.



Wow, sure sounds like I _really_ meant that *paralytics are always required*, doesn't it? <sarcasm> 

I explained my position on NMB in transport. My opinion is based on years of HEMS and CCT experience, a rather thorough understanding of mechanical ventilation and the drugs involved, and my resulting judgment on the advantages, disadvantages, risks, and benefits of using NMB vs. not using it. If you or anyone else disagrees with me, perfectly fine - lots of smart, experienced people do. I can't think of any topic in medicine that every clinician is 100% in agreement on. 


Look, I enjoy discussing these issues, and I'm happy to explain and defend my opinions and debate the options with you or anyone else. But I don't come here to argue, and I have no interest in posting here if half the time I do, I'm forced to spend more time clarifying my position to those who intentionally misrepresent it than I do actually discussing the clinical issue at hand.


----------



## Nitsud21 (Feb 3, 2015)

zzyzx said:


> To the original poster...are you sure that your protocols allowed you to transport propofol? Are you familiar with propofol at all?
> Regardless, you really should have refused. So you are not allowed to adjust the medication at all? What if the patient had become really hypotensive, as often happens with that medication?
> This should have been a CCT transport.
> I hope this doesn't come across as me being too critical of you. I think you were placed in a bad position by someone at the hospital, and perhaps because they were an MD or a charge nurse, you thought they knew better.



We are permitted to transport it but unable to titrate. The medics at my company have been talking about this for awhile and we are trying to make a change because it isn't right for the patient at all. We need to either have a set protocol for an alternative if the patient is not staying sedated or I will not transport at all.


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## zzyzx (Feb 3, 2015)

No one can stop you from simply refusing to transport. If something bad happens, you cannot make the excuse that a "higher" medical authority told you it was okay. 
You are aware that this is the drug that killed Michael Jackson, right? 
You really need to talk to your medical director.


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## Tigger (Feb 3, 2015)

zzyzx said:


> No one can stop you from simply refusing to transport. If something bad happens, you cannot make the excuse that a "higher" medical authority told you it was okay.
> You are aware that this is the drug that killed Michael Jackson, right?
> You really need to talk to your medical director.



Well that and boatload of benzos also found in his system. And the rather off label use. But yea, same thing. 

Your first point is spot on, however.


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## zzyzx (Feb 3, 2015)

I have used propofol countless times and I'm not saying it is some kind of nasty, dangerous medication, but in the hands of someone who doesn't know WTF they are doing, like MJ's doctor, it certainly can be. The general public knows that MJ died because of this drug, so if you are a healthcare provider and something bad happens to your patient and this medication was in play, you can be sure that the lawyers will using this to their advantage in a jury trial. If someone is transporting a patient on propofol and they don't know the first thing about it, it would really not be difficult for any lawyer to make the case that this is negligent because, well, it obviously is.


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## 18G (Feb 3, 2015)

It is a really bad policy to allow a Paramedic to transfer a patient on propofol but not allow them to titrate it. Very risky and definitely not in the best interest of the patient. In your case I would have given the patient fentanyl. Fentanyl and propofol is a great combination. The patient was receiving a decent dose at 40mcg/kg/min. Provide some analgesia and you probably would have had a patient much more comfortable and easier to manage.


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## 18G (Feb 3, 2015)

Remi said:


> Just as you have in previous discussions, you are mischaracterizing what I wrote.
> 
> I never said that paralytics are _always_ _required_. What I said they have zero downsides, are more predictable and have fewer side effects than the doses of sedation that may be required to keep a patient still in lieu of NMB, and that many who do these transports don't have the experience with ventilators and sedatives that is required to keep a patient comfortable and safe with sedation alone. And that therefore, I think using them routinely is _a good idea_.



If an adequate level of sedation isn't being achieved than why are we wanting to paralyze? This kind of makes me cringe. If the patient isn't comfortable with sedation alone they surely aren't going to be anymore comfortable with a paralytic onboard. It will just appear that the patient is more comfortable because they aren't moving which only makes the provider more comfortable, not the patient. 

I agree that more times than not paralytics are not required when a good combination of sedation and analgesia is used.


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## triemal04 (Feb 3, 2015)

Look, remi, I'm sorry, but nothing is being taken out of context.  Nothing is being mischaracterized.  You said:


Remi said:


> Lastly, I am of the firm belief that,* baring a good reason not to (and I can think of very few reasons not to), all intubated patients should be paralyzed for transport.* It simply makes things easier and safer


And then you followed it up with things like:


> there are virtually zero downsides to using NMB's
> 
> the bottom line is, the idea that it's somehow better for patients to avoid NMB in transport is one of the many EMS myths out there.
> 
> ...


You then gave some examples of why you thought a paralytic was indicated, though all those situations would have been solved by better *sedation*, not paralysis.

I'm very sorry, but all that taken with the rest of your posts here makes it come across clearly that you believe that ALL intubated patients should be paralyzed for* transport *(I may not have been clear about that in my first post) because it's easier and not harmful.  If that is NOT what you really think, you need to reconsider your delivery and what you've said, because what you may actually believe is not what comes across.


Remi said:


> Look, I enjoy discussing these issues, and I'm happy to explain and defend my opinions and debate the options with you or anyone else. But I don't come here to argue, and I have no interest in posting here if half the time I do, I'm forced to spend more time clarifying my position to those who intentionally misrepresent it than I do actually discussing the clinical issue at hand.


That is one of the most childish statements I have ever seen.


----------



## Carlos Danger (Feb 3, 2015)

18G said:


> If an adequate level of sedation isn't being achieved than why are we wanting to paralyze? This kind of makes me cringe. *If the patient isn't comfortable with sedation alone they surely aren't going to be anymore comfortable with a paralytic onboard*. It will just appear that the patient is more comfortable because they aren't moving which only makes the provider more comfortable, not the patient.
> 
> I agree that more times than not paralytics are not required when a good combination of sedation and analgesia is used.



This is a common misconception. Movement, asynchrony, and even tachycardia and hypertension are not specific signs of awareness or pain.

Whether the appropriate response is to give more sedation, or more analgesia, or do something else depends on several factors. But more fentanyl and more propofol isn't always the best route.

Edit: in the OP's situation, more sedation was (unfortunately, at only 40 mcg) not an option.


----------



## Carlos Danger (Feb 3, 2015)

triemal04 said:


> Look, remi, I'm sorry, but nothing is being taken out of context.  Nothing is being mischaracterized.  You said:
> 
> And then you followed it up with things like:
> 
> ...



Blah blah blah. Take some responsibility for your argumentativeness.

You are beating a dead horse.


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## triemal04 (Feb 3, 2015)

Remi said:


> Blah blah blah. Take some responsibility for your argumentativeness.
> 
> You are beating a dead horse.


That's fine.  We don't need to continue.  But, do me this favor.  I don't seem to be the only person who has taken what you've said to mean that your belief is that all patients should be paralyzed for transport (or was the only one in a different thread on a differnt subject).  If that isn't what you think, you may want to consider what you've said and how it's being taken by several people.


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## 18G (Feb 3, 2015)

Remi said:


> This is a common misconception. Movement, asynchrony, and even tachycardia and hypertension are not specific signs of awareness or pain.
> 
> Whether the appropriate response is to give more sedation, or more analgesia, or do something else depends on several factors. But more fentanyl and more propofol isn't always the best route.
> 
> Edit: in the OP's situation, more sedation was (unfortunately, at only 40 mcg) not an option.



The propofol with addition of fentanyl statement was not meant to be a blanket statement. You're right. It may not be the best route and some patients may require a different strategy. In my experience however, treating the patient with adequate doses of fentanyl often allows for lower doses of propofol and together you achieve a comfortable and well sedated patient. 

I've heard the argument from a few others that all patient's should be paralyzed for transport and I personally do not subscribe to that practice. If it's necessary to gain ventilator compliance or control of the patient because it is difficult to put the patient down with sedation/analgesia alone, than ok I see the indication.


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## medicaltransient (Feb 5, 2015)

I had a similar Pt one time I was fighting the Pt coming out of sedation and fighting hypotension. I followed my protocol for intubated Pt and gave 8mg Vecuronium 5mg of Versed and threw that Dipervan in the trash. When at the recieving facility the MD asked me where the Dipervan was I said in the trash where it belongs, he just laughed.


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## SeeNoMore (Feb 5, 2015)

medicaltransient said:


> I had a similar Pt one time I was fighting the Pt coming out of sedation and fighting hypotension. I followed my protocol for intubated Pt and gave 8mg Vecuronium 5mg of Versed and threw that Dipervan in the trash. When at the recieving facility the MD asked me where the Dipervan was I said in the trash where it belongs, he just laughed.


 
I'm not sure I understand. Are you saying that the Propofol belonged in the trash for this patient because of their hypotension or that you feel Propofol is generally a poor agent for the sedation of intubated patients during transport?  What indications does your airway / vent management protocol give for the use of NMB? Does it include options for analgesia?

In any event, I have found this discussion interesting. I use propofol often and am able to initiate , titrate and bolus it as we deem appropriate. Like others I view it as a useful agent and do not routinely paralyze patients. However I am certainly willing to if there is a need. I think the vast majority of providers fall in the middle of the two semi fictional extremes of "never paralyze a patient" and "always use paralytics".


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## medicaltransient (Feb 5, 2015)

SeeNoMore said:


> I'm not sure I understand. Are you saying that the Propofol belonged in the trash for this patient because of their hypotension or that you feel Propofol is generally a poor agent for the sedation of intubated patients during transport?  What indications does your airway / vent management protocol give for the use of NMB? Does it include options for analgesia?
> 
> In any event, I have found this discussion interesting. I use propofol often and am able to initiate , titrate and bolus it as we deem appropriate. Like others I view it as a useful agent and do not routinely paralyze patients. However I am certainly willing to if there is a need. I think the vast majority of providers fall in the middle of the two semi fictional extremes of "never paralyze a patient" and "always use paralytics".


I don't think it is not useful at all. I think it is less useful in the transport setting than in a stationary bed. For this patient it belonged in the trash because it was causing hypotension and was doing a poor job of sedating the patient. This was a wet CVA patient and the lack of paralysis and sedation probably caused spikes in ICP. I routinely paralize patients because that is how the protocol reads.


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## Nova1300 (Feb 5, 2015)

I agree that propofol is not an ideal agent for transport.  Being pretty comfortable and familiar with most of these drugs, my ideal transport cocktail would be primarily based on hefty doses of opiates.  Adjuncts available thereafter, though propofol would not be my first choice.  CC medics need to have a constant vigilance over the patient's hemodynamics, as transport is a very high-risk time for deterioration in the setting of critical illness.  And propofol, in a patient with inadequate analgesia, can become a dosing wrestling match.  It can be a major distraction at a time when vigilance and monitoring are of utmost importance.  I watch it happen in the ICU.  I'm sure it is no better in the back of moving vanbulance.  

I'm also believe paralysis for transport should not be routine.  It should certainly be available when indicated for the patient's illness or when adequate sedation cannot be achieved in an agitated patient due to instability.  Absent studies showing that routine paralysis for transport is superior, I think you are hard-pressed to justify it for transport in a calm, comfortable patient simply because you are transporting.


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## jwk (Feb 9, 2015)

Remi - you're right.  Period.  Really.


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## 18G (Feb 9, 2015)

Ive had good results with propofol in the transport setting. Why does it matter if used stationary or while moving interfacility as suggested? 

What was the dose of propofol? I'm curious to know if fentanyl was used to keep the propofol dose on the low side or if sedation was attenpted without analgesia. Also curious to know if a fluid bolus was tried to counter the hypotension.


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## Merck (Feb 10, 2015)

Propofol works very well in transport.  Perhaps it is a question of experience and training.  The notion of not being able to titrate is crazy.

As for the idea of paralyzing anyone for transport - no dice.  Perhaps I'm not getting the context of the transports as I work in a different system.  There are many reasons not to paralyze anyone.  It can interfere with ongoing care, mask issues, and cause HD stability.  There are lots of times when it is indicated - but a blanket policy of paralytics 'for transport' is medieval. 

I'm with 18G on that point - why does it matter if it's stationary or in transport?  Paramedics can do themselves a disservice by throwing around 'transport environment' as a reason to depart from good critical care.


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## Carlos Danger (Feb 10, 2015)

18G said:


> Ive had good results with propofol in the transport setting. Why does it matter if used stationary or while moving interfacility as suggested?





Merck said:


> I'm with 18G on that point - why does it matter if it's stationary or in transport?



The difference between using propofol in the ICU vs. in transport is simply that there is much more stimulus in transport, so you need more sedative to maintain the same level of comfort.

Propofol _always works_......as long as you can use enough of it. The limiting factor in propofol dosing is its dose-dependent effects as a vasodilator and direct myocardial depressant. The more of it that you use, the less favorable the hemodynamic results.

When used alone in a stimulating environment, you can sometimes reach a point of diminishing returns with propofol at a surprisingly low dose range......where going up on the dose does more to drop the BP than it does to keep the patient still. I think this has more to do with patient-specific physiologic and pharmacologic factors than it does with the propofol itself, but it can be difficult to predict, especially if you don't know the patient and their history well, and even more so if you aren't experienced in these scenarios.

The problem of diminishing returns can usually be remedied or at least minimized by replacing some of the propofol with opioid.....my guess is that those among us who have never or rarely had bad experiences with propofol in transport can say that because they have protocols that call for healthy doses of opioid for these patients.


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## Carlos Danger (Feb 10, 2015)

Merck said:


> There are many reasons not to paralyze anyone.  It can interfere with ongoing care, mask issues, and cause HD stability.



Can you give examples of what type of ongoing care is interfered with by NMB, as well as how it can cause hemodynamic instability?


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## Merck (Feb 10, 2015)

Granted the HD instability is rare, but NMBAs can cause hypotension through histamine release.  As well, if a patient has some inherent pull on the vent (i.e. PSV) then paralyzing them could affect their HD status as you transition them to full vent support.  (both admittedly minor issues and can be anticipated and compensated for).

My issue with the 'paralysis for everyone' approach is if this is employed without reference to the patient's condition.  If a patient can do quite well on pressure support, why paralyze them and plop them onto whatever generic settings you use for transport?  As well, while it can be good for dysynchrony, I believe paralytics should be used after attempts to troubleshoot the dysynchrony in the first place.  A lot of cases of dysynchrony can be solved with a little medication titration and adjusting flows.

As for the propofol, I think it's obvious that there are downsides to it - it is certainly not for everyone.  Like any other drug it has it's uses and dangers and should be used appropriately and titrated with reference to a patient's state and hemodynamics.  I move people in planes, jets and helicopters (and the odd hovercraft), as well as by ground and propofol can be used effectively in the right patient.  If one has propofol on the wrong patient however (i.e. cardiogenic shock), then I think you have a whole new set of issues to deal with.


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## Nova1300 (Feb 10, 2015)

Merck said:


> Granted the HD instability is rare, *but NMBAs can cause hypotension through histamine release.*  As well, if a patient has some inherent pull on the vent (i.e. PSV) then paralyzing them could affect their HD status as you transition them to full vent support.  (both admittedly minor issues and can be anticipated and compensated for).
> 
> My issue with the 'paralysis for everyone' approach is if this is employed without reference to the patient's condition.  If a patient can do quite well on pressure support, why paralyze them and plop them onto whatever generic settings you use for transport?  As well, while it can be good for dysynchrony, I believe paralytics should be used after attempts to troubleshoot the dysynchrony in the first place.  A lot of cases of dysynchrony can be solved with a little medication titration and adjusting flows.
> 
> As for the propofol, I think it's obvious that there are downsides to it - it is certainly not for everyone.  Like any other drug it has it's uses and dangers and should be used appropriately and titrated with reference to a patient's state and hemodynamics.  I move people in planes, jets and helicopters (and the odd hovercraft), as well as by ground and propofol can be used effectively in the right patient.  If one has propofol on the wrong patient however (i.e. cardiogenic shock), then I think you have a whole new set of issues to deal with.




Hmmmmmm.  Which drug are you using?


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## Merck (Feb 10, 2015)

We use roc so don't have much issue.  It was more of an info point on some of the other non-depolarizers.  I have no idea what other services use.  I'm sure the point is minor.


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## Nova1300 (Feb 10, 2015)

Merck said:


> We use roc so don't have much issue.  It was more of an info point on some of the other non-depolarizers.  I have no idea what other services use.  I'm sure the point is minor.



You're right, histamine release with most muscle relaxants is not clinically important.  

The second issue you bring up is very relevant.  And I think a lot of us medical folks think we understand what's going on when we don't fully.  

I see it in very sick patients who had spontaneous ventilatory effort, assisted or unassisted, who following muscle relaxation (even with minimal or no induction agent) develop profound hypotension.  And in my own experience it tends to be minimally responsive to fluid blouses, which I think is strange given that most of these patients are intravascularly volume depleted.  

My best guess is the loss of negative intrathoracic pressure and transition to a positive pressure ventilation is impeding venous return.  But, I'm unconvinced.  

Nonetheless, it's another tick in my 'avoid relaxants if possible' box.  

To add one more: a lot of medications are given in the operating room.  A whole regimen of drugs for each case.  And of all those drugs, the number one culprit for anaphylaxis in the OR : muscle relaxants. 

Definitely things to add to your risk:benefit ratio before you pull out paralytics needlessly.


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## Carlos Danger (Feb 11, 2015)

Nova1300 said:


> I see it in very sick patients who had spontaneous ventilatory effort, assisted or unassisted, who following muscle relaxation (even with minimal or no induction agent) develop profound hypotension.  And in my own experience it tends to be minimally responsive to fluid blouses, which I think is strange given that most of these patients are intravascularly volume depleted.
> 
> My best guess is the loss of negative intrathoracic pressure and transition to a positive pressure ventilation is impeding venous return.  But, I'm unconvinced.



This is the definitely current thinking, at least as I understand it. I've seen significant hypotension on intubation & initiation of PPV, but it's really not an issue of NMB vs. no NMB, is it? It's more an issue of the transition from spont. V or PSV to full PPV. If you can avoid PPV, then by all means do. But if you can't avoid PPV, then I don't see how choosing to use NMB is going to make the PPV-induced hypotension worse.



Nova1300 said:


> To add one more: a lot of medications are given in the operating room.  A whole regimen of drugs for each case.  And of all those drugs, the number one culprit for anaphylaxis in the OR : muscle relaxants.
> 
> Definitely things to add to your risk:benefit ratio before you pull out paralytics needlessly.



The anaphylaxis thing is interesting. I just came across a few things about this recently. Very broad estimates of incidence, I've seen anything from 1:1000 up to 1:100,000, with 1:10,000-1:20,000 being the most common range cited, with severe reactions of course being much less common than less severe ones. Also the most common offending agents vary, with some sources saying roc, some saying vec, but most blaming sux as most likely to cause a problem.

Yet, we still give the stuff out like candy in the OR....in my training I never once heard someone say "let's try to avoid the NMB so that we don't cause any increased risk of a reaction". Not that such nonchalance is evidence that we shouldn't consider it, of course, but the point is I think we generally accept the small risk of a severe reaction as much lower than the likely benefits of the drug. As we generally do with all the drugs we give routinely. If the drug is indicated, it's probably well worth the risk. If it isn't indicated, then it's not. With the NMB-in-transport issue, it all comes down to whether we consider them "indicated" or not.

There was an interesting article published in PEC a few years ago that retrospectively looked at HEMS transports of intubated patients in Ontario, CA. It was more of a descriptive article but they did some post-hoc analysis, too. Found a 17% incidence of "critical events" during transport, mostly hypotension that appeared to be mostly related sedative dosing. I think NMB was given in something like 20% of the transports.


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## jwk (Feb 11, 2015)

Nova1300 said:


> the number one culprit for anaphylaxis in the OR : muscle relaxants.


You gotta source for that claim, because I couldn't disagree more.


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## Nova1300 (Feb 11, 2015)

jwk said:


> You gotta source for that claim, because I couldn't disagree more.


Dude, it's on the boards.


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## Nova1300 (Feb 11, 2015)

Quick google search


http://www.ncbi.nlm.nih.gov/m/pubmed/18475086/


Though I thought it was common knowledge among anesthesia folk.


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## jwk (Feb 12, 2015)

Nova1300 said:


> Quick google search
> 
> 
> http://www.ncbi.nlm.nih.gov/m/pubmed/18475086/
> ...


That article is 7 years old.  Atracurium, which was the worst of the NMB offenders for allergic reactions, is rarely found in clinical use any more, if at all.  Rocuronium just isn't a huge problem for anaphylaxis.  The worst offenders are antibiotics and latex.


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## Nova1300 (Feb 12, 2015)

jwk said:


> That article is 7 years old.  Atracurium, which was the worst of the NMB offenders for allergic reactions, is rarely found in clinical use any more, if at all.  Rocuronium just isn't a huge problem for anaphylaxis.  The worst offenders are antibiotics and latex.



I guess somebody better call Ronald Miller and let him know that his textbook is wrong.  Let him know it's page 1110.


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## Nova1300 (Feb 12, 2015)

Jwk, since you are the second person to speak up about this histamine release phenomena-  

Histamine release from any neuromuscular blocker is not really of clinical importance.  At worst, the histamine release is brief and causes skin flushing, occasionally mild hypotension.  The reaction dissipates within 2 minutes and hemodynamics normalize, if they were ever altered to begin with.  These reactions are rare when the medication is dosed appropriately and given slowly.  

Histamine release is not a reason to avoid a neuromuscular blocker of any class.  

And I would hope that most physicians could differentiate between this and anaphylaxis.


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## Carlos Danger (Feb 13, 2015)

jwk said:


> That article is 7 years old.  Atracurium, which was the worst of the NMB offenders for allergic reactions, is rarely found in clinical use any more, if at all.  Rocuronium just isn't a huge problem for anaphylaxis.  The worst offenders are antibiotics and latex.



The most recent editions of all the major texts (Barash, Miller, M&M, Longenecker, Nagelhout) mention NMB as a common - if not the most common - cause of preoperative anaphylactoid reactions.

There's quite a bit about it in the recent literature, too. The one that is cited mostly in the texts was done in France and found that 55% of reactions were due to NMB (vs. 23% to latex and 14% to ABX), most commonly to sux. Another one found that sux and roc were far more likely to cause reactions than atracurium. 

From M&M 5th edition, page 2013:
_Muscle relaxants are the most common cause of anaphylaxis during anesthesia, with an estimated incidence of 1 in 6500 patients. They account for almost 60% of perioperative anaphylactic reactions. In many instances, there was no previous exposure to muscle relaxants. Investigators suggest that over-the-counter drugs, cosmetics, and food products, many of which contain tertiary or quaternary ammonium ions, can sensitize susceptible individuals. A French study found that, in decreasing order of frequency, rocuronium, succinylcholine, and atracurium were most often responsible; this likely reflects the propensity to cause anaphylaxis, together with frequency of use. _​


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## Vegeta182 (Feb 23, 2015)

I just had the wrist transfer in my 9 years of ems. The cause? Improper dosage of propofol. I did two things wrong. The first was not knowing the dosage range for the propofol drip. The second trusting an ed doctor's prescribed dose. I had a 2 year old traumatic brain injury. Depressed skull fracture. The ed department called my company and had me there before they had even thought about transferring the patient. As time went by the pediatric trauma surgeon told the ed doctor to intubate the patient. They used amidate and vec. Then attempted to run propofol through an I.O in the tibia. The vec wears off and the error on dosing of the propofol becomes readily apparent. They had a 16kg 2 year old on 8mg/hr that was   .8 ml/hr seem slow? It was. The doctor tells me to titrate by going up by  .1 increments. Then they push me out the door no vent just bvm. I make it to 1.4ml/hr nothing the kid is fighting so I turn around and demand the patient be properly sedated before I go again. They give me 2 doses of vec and 2 doses of ativan. It is a 2 and a half hour transport. I use up the doses and ultimately diverted to a hospital on the way. Turns out the drip should have been around 14ml/hr. In the end painful lesson learned. I can always learn something I just hate it was that way. We rarely have pediatric propofol transports so I didn't have it on the front of my mind also my references had the dosage in mcg/kg/min.


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## CANMAN (Feb 26, 2015)

Vegeta182 said:


> I just had the wrist transfer in my 9 years of ems. The cause? Improper dosage of propofol. I did two things wrong. The first was not knowing the dosage range for the propofol drip. The second trusting an ed doctor's prescribed dose. I had a 2 year old traumatic brain injury. Depressed skull fracture. The ed department called my company and had me there before they had even thought about transferring the patient. As time went by the pediatric trauma surgeon told the ed doctor to intubate the patient. They used amidate and vec. Then attempted to run propofol through an I.O in the tibia. The vec wears off and the error on dosing of the propofol becomes readily apparent. They had a 16kg 2 year old on 8mg/hr that was   .8 ml/hr seem slow? It was. The doctor tells me to titrate by going up by  .1 increments. Then they push me out the door no vent just bvm. I make it to 1.4ml/hr nothing the kid is fighting so I turn around and demand the patient be properly sedated before I go again. They give me 2 doses of vec and 2 doses of ativan. It is a 2 and a half hour transport. I use up the doses and ultimately diverted to a hospital on the way. Turns out the drip should have been around 14ml/hr. In the end painful lesson learned. I can always learn something I just hate it was that way. We rarely have pediatric propofol transports so I didn't have it on the front of my mind also my references had the dosage in mcg/kg/min.




So many things wrong with this whole scenario..... Can't believe stuff like this happens. Hand bag a Pediatric TBI patient for over two hours WTH?!? Were you by yourself as a single ALS provider with this patient...? If so many mistakes were made, but all could have been prevented if you just said your not comfortable with this patient and medication that is infusing, and insisted on more resources, an air medical transfer, a nurse to go with, etc.... You as a provider, in my opinion, have a HUGE responsibility to know your limitations and verbalize them. When in doubt, do what is RIGHT for the patient.


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## Carlos Danger (Feb 26, 2015)

Vegeta182 said:


> I just had the wrist transfer in my 9 years of ems. The cause? Improper dosage of propofol. I did two things wrong. The first was not knowing the dosage range for the propofol drip. The second trusting an ed doctor's prescribed dose. I had a 2 year old traumatic brain injury. Depressed skull fracture. The ed department called my company and had me there before they had even thought about transferring the patient. As time went by the pediatric trauma surgeon told the ed doctor to intubate the patient. They used amidate and vec. Then attempted to run propofol through an I.O in the tibia. The vec wears off and the error on dosing of the propofol becomes readily apparent. They had a 16kg 2 year old on 8mg/hr that was   .8 ml/hr seem slow? It was. The doctor tells me to titrate by going up by  .1 increments. Then they push me out the door no vent just bvm. I make it to 1.4ml/hr nothing the kid is fighting so I turn around and demand the patient be properly sedated before I go again. They give me 2 doses of vec and 2 doses of ativan. It is a 2 and a half hour transport. I use up the doses and ultimately diverted to a hospital on the way. Turns out the drip should have been around 14ml/hr. In the end painful lesson learned. I can always learn something I just hate it was that way. We rarely have pediatric propofol transports so I didn't have it on the front of my mind also my references had the dosage in mcg/kg/min.



I agree with CANMAN, you definitely have a responsibility as a paramedic to speak up and say "look, I'm just not equipped to do this safely. I don't have a vent, I'm not familiar with the drugs, etc....let's get someone here who does this type of thing every day, OR send someone with me who does". I know that is easier said than done, but still.

Maybe getting someone else to do the transport wasn't an option. Maybe there were no PICU nurses at the referring, and the ED nurses weren't any more familiar than you are (the ED doc certainly wasn't). Or maybe it just wasn't possible to send an ED nurse away for 6 hours. If that's how it is where you work though, you should expect to do this type of thing occasionally and at a bare minimum, know something about propofol (it isn't like it's an exotic drug that a paramedic will never see) and how to dose it and most importantly, have the guts to refuse to do the transport unless they give you orders to titrate the sedation appropriately. Also know the appropriate dosing of opioids to augment the sedation in these cases.


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## Vegeta182 (Mar 1, 2015)

Thank you guys for reviewing my call from your computer desk or phone and using the power of hindsight to tell me all that I had done wrong. Everything stated above was already realized by me during and soon after the call. Maybe you guys are above getting caught up in a frantic er pushing a patient out the door, maybe if you had never transported a pediatric propofol drip in 9 years of working the dosage would be on the forefront of your mind. Who knows? External criticism is weak compared to internal and I've had plenty of time for that on my own. There were no nurses, medflight was grounded, there was no pediatric truck that run those calls daily. They're was only me and the ill equipped band aid station of an er. There is only the ambulance service I work for in the whole County and it was me working. I could have left him at the er to die I guess or do my best to get him to a better facility.


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## Carlos Danger (Mar 1, 2015)

Vegeta182 said:


> Thank you guys for reviewing my call from your computer desk or phone and using the power of hindsight to tell me all that I had done wrong. Everything stated above was already realized by me during and soon after the call. Maybe you guys are above getting caught up in a frantic er pushing a patient out the door, maybe if you had never transported a pediatric propofol drip in 9 years of working the dosage would be on the forefront of your mind. Who knows? External criticism is weak compared to internal and I've had plenty of time for that on my own. There were no nurses, medflight was grounded, there was no pediatric truck that run those calls daily. They're was only me and the ill equipped band aid station of an er. There is only the ambulance service I work for in the whole County and it was me working. I could have left him at the er to die I guess or do my best to get him to a better facility.



Good job.


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## triemal04 (Mar 1, 2015)

Part of learning and improving is being able to understand and appreciate CONSTRUCTIVE criticism.  While you came to ask a specific question, you relayed a scenario that has a multitude of things wrong with it.  Did you expect that nobody would realize that and point out those flaws?  (and believe me, the responce from canman and remi has been TAME to say the least)  It's good that you already realize that you had a problem beyond your stated question; that says a lot about you as a provider (I mean that in a good way).  If you have already started to work on correcting the things that you have identified as a problem, that says a lot about you as a provider (that is definetly meant in a good way).

But if you are going to get pissy when your faults are pointed out, that also says a lot about you as a provider.

That is not meant in a good way.

If you want to dissect the entire call, that can be done.  More information is needed, but I can point to at least half a dozen things right now that were done wrong and/or should have been done better.  If that's the direction you want to go we can, because EXTERNAL criticism plays a large part in career development and can be a good thing, especially when someone may not have the ability to criticize themselves INTERNALLY, or may not see all the problems.

Do you really think that you are the first, or last person to be put into that same type of situation, or a worse one?  I've been there.  There's probably other people here who have done the same.

It can be time to learn...or not.


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## Vegeta182 (Mar 1, 2015)

I agree with you completely. Going by what you are saying about their replies being mild compared to some. I guess I was looking for a sense of brotherhood and someone offering to talk about it. It seems though that this isn't the place if I'm to expect much worse criticism. It seems like there are few people like you on here. I think I will have better luck talking to someone in the real world. I really do appreciate your kind response and input though. I hate that you interpreted my response as "pissy"


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## Carlos Danger (Mar 2, 2015)

Vegeta182 said:


> I was looking for a sense of brotherhood and someone offering to talk about it.


CANMAN and I both replied, which is the internet equivalent of "offering to talk about it".




Vegeta182 said:


> It seems though that this isn't the place if I'm to expect much worse criticism.


You posted in the middle of a clinical discussion on the role of propofol in transport. I'm not sure why you thought the response would be anything other than a continuation of that clinical discussion.



Vegeta182 said:


> I hate that you interpreted my response as "pissy"


Your response to my reply (which was meant to be helpful and constructive, BTW) seemed very pissy, and it came off as thin-skinned and unwilling to accept much-needed advice. If you weren't looking for clinical discussion, you shouldn't have posted in the middle of a clinical discussion....


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## CANMAN (Mar 2, 2015)

Vegeta I am sorry you feel like my reply was an attack and not constructive. The beginning of my reply post was more dumbfounded at the fact that the patient was so mismanaged at the sending facility, and no one in said scenario said "time out, is what we are doing here make sense." Ultimately that level of responsibility rests with the sending MD, however as we have pointed out the transporting provider also owns a piece of that puzzle. 

One thing you have to understand is this forum can certainly be a sounding board, or a learning tool, and sometimes the best feedback or criticism may not come with a hug and feel good vibe to it.... When I first started to do critical care transport there may have been a few times in my career where I was put in situations like this, but the feedback I got from other senior provider's, my medical director at the time, etc molded me into the provider I am today. It is extremely hard as a provider to call a time out and say I am not comfortable, and I don't know if I possessed that ability as a new Paramedic, however you said you haven't transported a peds/propofol call in 9 years which leads me to believe you have been doing this a while. Maybe this call was an eye opening and made you realize what you need to brush up on, or when to sound off that your out of your comfort zone. 

Regardless of what you take from the forum, realize there are a lot of extremely experienced and knowledgeable provider's here on the forum with varying backgrounds and education levels. The only reason I am on here is to learn from people with more knowledge then I have and I find bouncing ideas off each other, replying to scenarios with what you would have done, and seeing how other's would do it/what they know about X,Y,Z is a great way to realize what you don't know, or need to know more of.....

Rarely, if ever, is anyone attacking another provider on the forum and it is monitored for such. Sorry the replies seemed harsh to you, but take it in stride and maybe ask questions on how it could have gone better and provide more details, and some of the replies MIGHT give you the knowledge to make it go great the next time. 

Cheers, 
CANMAN


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## SandpitMedic (Mar 2, 2015)

Wowza. I'm interested in what happened after that. Did the kid make it? Did the ER doc catch any flak? Did you raise any concerns with the county health dept?

8mg/hr?! Wtf? He could not have screwed that up more.

Google could have been everyone's friend there too in (what was) the worst case scenario.

My protocol here is 2mg/kg loading dose and a .5mg/kg/min drip or 1mg/kg push every 2 minutes. Better to have a pump.


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## Vegeta182 (Mar 2, 2015)

I did raise concerns and looking back he should have been around 200 mcg/kg/min on the drip which would have been 192 mg/hr compared to the 8mg/hr the doctor had him on. I appreciate your response canman. I certainly did have a wake up call on some things I need to brush up on. You are also right that it is very hard to call a time out and reflect in ssome situations. I think my biggest problem with this call was my blind faith in the ER doctor and nurses. This was from a hospital and area that I was unfamiliar with. My company had me there covering someone's shift. You learn er doctors and nurses overtime and you also learn when to trust them and when not to. I went in to this call with a whole er of strangers. SandpitMedic as far as I know the doctor hasn't caught any flak for it. I do need to day this. He was diagnosed with a depressed skull fracture with brain injury. While theppatient had a legitimate coup contractual injury it was found at the accepting hospital that he never had a depressed skull fracture. The kid is now extubated and seems to have no permanent focal deficit.


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## CANMAN (Mar 3, 2015)

Vegeta182 said:


> I did raise concerns and looking back he should have been around 200 mcg/kg/min on the drip which would have been 192 mg/hr compared to the 8mg/hr the doctor had him on. I appreciate your response canman. I certainly did have a wake up call on some things I need to brush up on. You are also right that it is very hard to call a time out and reflect in ssome situations. I think my biggest problem with this call was my blind faith in the ER doctor and nurses. This was from a hospital and area that I was unfamiliar with. My company had me there covering someone's shift. You learn er doctors and nurses overtime and you also learn when to trust them and when not to. I went in to this call with a whole er of strangers. SandpitMedic as far as I know the doctor hasn't caught any flak for it. I do need to day this. He was diagnosed with a depressed skull fracture with brain injury. While theppatient had a legitimate coup contractual injury it was found at the accepting hospital that he never had a depressed skull fracture. The kid is now extubated and seems to have no permanent focal deficit.




Where are you getting those dosages from...? Your dosing is off. At 200mcg/kg/minute your running total IV anesthesia. REMI can tell you more about that.

For a 16kg kid with a TBI I would be shocked if you needed more then 50mcg/kg/min to sedate him, and I would also provide some opioid analgesia....

So say 50mcg x 16kgs = 800mcg/minute or 4.8ml/hr using standard concentration propofol...


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## Vegeta182 (Mar 3, 2015)

He was actually very combative. I was going by the dosage the pediatric trauma physician ultimately put him on at the facility I diverted to. I'm guessing the anesthetic dosage was to insure ICP wasn't being spiked?


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## Carlos Danger (Mar 3, 2015)

200 mcg/kg/min is a lot of propofol. Not saying it was inappropriate in this case - obviously I wasn't there - but it's well into the range where you would expect to need pressors to offset the hypotensive effects, and hypotension is one of the worst things you can let happen to someone with a compensatory increased ICP.


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## Vegeta182 (Mar 3, 2015)

I agree remi but the dose I was sent with was severely under the effective for for sedation. In the future  I will be more aware of the pediatric dosages for drugs that are uncommon in my transfers. We don't have protocols for propofol or any sedatives or paralytics for that matter other than valium. We pretty much have to go by what the sending facility doctor orders. At the end of the day I learned a big lesson in not becoming compliant in continuing my education and keeping knowledge like this fresh in my mind.


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## Carlos Danger (Mar 3, 2015)

200 wasn't enough? Or do you mean the initial dose?

I understand that you are bound by lack of protocol and drugs and that you have to use what you are sent with. A typical dose range for prop for vent sedation would be like 25-100 or so mcg/mcg/min. Adding a healthy dose of opioid and titrating the prop on top of it is a good technique. I'm personally a fan of NMB as well, but I'm in the minority on that here.


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## chaz90 (Mar 3, 2015)

Was the IO entirely patent and running freely? Just saying...I know it can be very difficult on some kids. Just wondering if the entire dose wasn't reaching the CNS effectively.


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## Vegeta182 (Mar 3, 2015)

It was patent the drip was just sadly to low.


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## VFlutter (Mar 4, 2015)

I do not think I have ever gone above 100mcg on Propofol. I know our pumps have a hardstop at 200mcg. Admittedly, I am sure a transport environment is much different however even during various procedures a little Fentanyl/Ativan on top does wonders. Propofol infusion syndrome and triglycerides are also a concern.


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## SeeNoMore (Mar 17, 2015)

Vegeta182 said:


> I agree remi but the dose I was sent with was severely under the effective for for sedation. In the future  I will be more aware of the pediatric dosages for drugs that are uncommon in my transfers. We don't have protocols for propofol or any sedatives or paralytics for that matter other than valium. We pretty much have to go by what the sending facility doctor orders. At the end of the day I learned a big lesson in not becoming compliant in continuing my education and keeping knowledge like this fresh in my mind.




Sounds like an awful call. I am glad that you are willing to take the time to improve. That being said, I think there is also a danger in expecting too much sympathy for poor decision making and care. As you well know it can cost our patients dearly. You are also part of a broader system which may need improvement. Was there no better option than a 2 hour transport with a single paramedic who admittedly was not prepared for a complex peds transport?  I know that sounds awful and harsh but bear with me. Just like you I have made mistakes and acted without proper information. Like you I have tried to improve. But to be honest there have been times when I found myself lacking in some area and knew full well I could have done a better job preparing or just made a better decision. No one is immune. We all have to be our harshest critics. 

And I think anyone involved in transport will attest that you have to stand up for yourself. You may have a MD or RN screaming at you to take a patient who you know full well is not stable, or that you do not have the ability to care for. In some situations you may end up transporting but at least make sure you CYA with a call to medical command / the accepting doc notifying them of the pt's condition , your resources and abilities, and get them to verbalize the cost / benefit of transport in less than ideal conditions vs further attempts at stabilization. 

I hope your week goes better.

Best ,


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