Propofol

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.
 
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.
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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. ​
 
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.
 
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.
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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.
 
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.
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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.
 
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.
 
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.
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Good job.
 
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.
 
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"
 
Vegeta182 said:
I was looking for a sense of brotherhood and someone offering to talk about it.
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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.
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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"
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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....
 
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
 
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.
 
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.
 
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.
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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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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?
 
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.
 
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.
 
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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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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