Propofol

[Tigger]

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.

 

[CANMAN]

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,

 

[Carlos Danger]

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.

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.

 

[triemal04]

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
• 3. Breaking restraints
• 4. Coughing and bucking
• 5. Moving their head enough to change the position of the ETT
• 6. 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.

(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.

 

[triemal04]

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.

 

[Carlos Danger]

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".

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.

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.

 

[triemal04]

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:

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]

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]

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]

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

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.

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:

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

And this one:

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

And this one:

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]

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.

 

[zzyzx]

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.

 

[Tigger]

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.

 

[zzyzx]

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.

 

[18G]

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.

 

[18G]

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.

 

[triemal04]

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

I do agree, you don't usually "need" it [paralytics]

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

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.

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]

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]

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:

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.

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

Blah blah blah. Take some responsibility for your argumentativeness.

You are beating a dead horse.

 

[triemal04]

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.