Propofol

[Nitsud21]

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!

 

[NomadicMedic]

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?

 

[Nitsud21]

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.

 

[CANMAN]

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......

 

[specwisconsin]

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

 

[NomadicMedic]

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.

 

[Nitsud21]

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!

 

[CANMAN]

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.

 

[WestMetroMedic]

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?

 

[CANMAN]

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.

 

[WestMetroMedic]

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!

 

[CANMAN]

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!

 

[Carlos Danger]

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.

 

[CANMAN]

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.

• 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.

- 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.

 

[Carlos Danger]

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.

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.

 

[CANMAN]

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.



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.

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.

 

[CANMAN]

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.

 

[systemet]

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

 

[Carlos Danger]

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.

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.

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.

 

[MonkeyArrow]

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).