Propofol / Ketamine / Etomidate in ED

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
Venko

Venko

True to self
Lifetime Donor
Verified Member
Physician
15+ Year Member
Platinum Member
Joined
Jan 24, 2006
Messages
734
Reaction score
476
I am curious about what everyone's thoughts are on the use of propofol, ketamine, etomidate being used for sedation in the ER by EM attendings.

I am an EM attending and found these medications to be supremely helpful for orthopedic reductions, complex lacerations, endoscopy, etc. What is everyone's thoughts on this?

TL
Members don't see this ad.
 
I think it's fine. You guys are smart enough to do it safely. I think there is a big difference between EM using those drugs while ortho or whoever does those procedures, versus the GI situation where a nurse (not an anesthesiologist or anesthetist) is pushing drugs and the GI is only paying attention to the procedure, not the sedation. Plus, you guys have airway skills, and GI doesn't.

Now if EM is using those drugs and then proceeding to suture up the laceration themselves, that's different and unsafe. Thankfully, I haven't spent enough time in the ER to see what really happens. Overall though, I think if we're picking battles, the one in the ER over the use of propofol is silly.
 
ThymeLess said:
I am curious about what everyone's thoughts are on the use of propofol, ketamine, etomidate being used for sedation in the ER by EM attendings.

I am an EM attending and found these medications to be supremely helpful for orthopedic reductions, complex lacerations, endoscopy, etc. What is everyone's thoughts on this?

TL
Click to expand...

Humbly disagree. Anesthesia drugs should be administered by anesthesia providers. The same arguments that hold in GI also hold for the ER, radiology, cardiology, and any other area that wants to do procedural sedation. In our facilities, by hospital policy, propofol, ketamine, etomidate, pentothal, and brevital are all limited to use by, and only available to, anesthesia providers. The only exception is propofol by infusion to ventilated patients in the ICU.
 
Members don't see this ad :)
You ED docs are very good physicians and deserve a bunch of credit for the crap you have to deal with. My compliments.

As for the propofol question...it is a very good drug for the types for short-term procedural needs you have, but IIRC, a few years ago I actually read the package insert from propofol and it said something like "to be administered only by personnel trained in anesthesia" or some such. I don't know if the manufacturer still says that.
 
The real issue here is access to care.

If the reimbursement was good then we, anesthesia, would make ourselves immediately available to perform the sedation. But since the reality is that the economics dont make it a convincing argument for us to go down to ED regularly we dont. This puts the ED docs and other providers, cardiologists, Ortho, looking for ways to get their patients what they need. At my institution propfol is restricted to anesthesia, so then the ED uses ketamine and etomidate. Unfortunately the worst outcomes i have seen with ED sedation have come when they use Versed and Fentanyl. At the current time most GI procedures are lucrative so we do them without hesitation.

So i guess my point is that there is ideal situations and reality. Ideally anesthesia would always perform the sedation but that would mean I would have to hire another DOC or CRNA to be available for this (or have to hold an OR while we went down to ED). Since the reimbursement would suck we would request the hospital to pony up some cash. That will never happen. So teach people how to use the drugs safely and when to ask for help.
 
ThymeLess said:
I am curious about what everyone's thoughts are on the use of propofol, ketamine, etomidate being used for sedation in the ER by EM attendings.

I am an EM attending and found these medications to be supremely helpful for orthopedic reductions, complex lacerations, endoscopy, etc. What is everyone's thoughts on this?

TL
Click to expand...

I personally have no problems with ED docs using these drugs. But I will say this: "proceed at your own risk!" Full stomachs (which are the majority of your patients), difficult AWs and specific patient considerations, i.e., specific medical conditions, warrant an anesthesiologist's consult before you get started with any sedation. Reason? There is not a single anesthesiologist I know who likes to run to the ED and see a f*cked up AW that has been already mucked up by the ED staff. We all have to realize our limits: when you know that it is a bad airway and/or a risky patient, you should get the anesthesiologist involved early! Do not burn any bridges and all will be well....:thumbup:
 
Is it time for this thread again? ;)

http://forums.studentdoctor.net/showthread.php?t=758889
http://forums.studentdoctor.net/showthread.php?t=782588


The facts as I see them:
  • The ED standard of care is not the same as our standard of care, particularly with regard to NPO guidelines. You're OK with a room air general anesthetic in a full stomach. We're not.
  • ICUs aren't full of ARDS patients who aspirated during reductions in the ED. For short procedures with no airway instrumentation, what you cowboys do doesn't appear to be especially risky. (I still wouldn't do it.)
  • ED physicians are certainly capable of managing an airway while sedating a patient.
  • Anesthesiologists have neither the time nor the inclination to come to the ED to do all of your sedations for you.
  • What you do with your license in your house ought to be regulated by your society. It's not really our place to boss you around.
All that said, if you ask a bunch of anesthesiologists about the proper way to sedate a non-NPO patient, we're going to tell you that the "ED way" isn't it.
 
The issue is to avoid apnea and any associated airway emergencies. The drug of choice for me would be small doses of ketamine (10-50mg) and midazolam (1-2mg). Ketamine avoids apnea and offers analgesia (no need for fentanyl). Small doses of midazolam (1-2mg) avoids recall of ketamine induced nightmares. During every sedation I perform, I always anticipate an emergent crash and possible burn. Have airway equipment and drugs drawn up (sux, atropine, epi) AT BEDSIDE AND READY to ROCK just in case.


ThymeLess said:
I am curious about what everyone's thoughts are on the use of propofol, ketamine, etomidate being used for sedation in the ER by EM attendings.

I am an EM attending and found these medications to be supremely helpful for orthopedic reductions, complex lacerations, endoscopy, etc. What is everyone's thoughts on this?

TL
Click to expand...
 
bullard said:
I think it's fine. You guys are smart enough to do it safely. I think there is a big difference between EM using those drugs while ortho or whoever does those procedures, versus the GI situation where a nurse (not an anesthesiologist or anesthetist) is pushing drugs and the GI is only paying attention to the procedure, not the sedation. Plus, you guys have airway skills, and GI doesn't.

Now if EM is using those drugs and then proceeding to suture up the laceration themselves, that's different and unsafe. Thankfully, I haven't spent enough time in the ER to see what really happens. Overall though, I think if we're picking battles, the one in the ER over the use of propofol is silly.
Click to expand...

We would have one provider perform the sedation and another provider perform the procedure.
 
IN2B8R said:
I personally have no problems with ED docs using these drugs. But I will say this: "proceed at your own risk!" Full stomachs (which are the majority of your patients), difficult AWs and specific patient considerations, i.e., specific medical conditions, warrant an anesthesiologist's consult before you get started with any sedation. Reason? There is not a single anesthesiologist I know who likes to run to the ED and see a f*cked up AW that has been already mucked up by the ED staff. We all have to realize our limits: when you know that it is a bad airway and/or a risky patient, you should get the anesthesiologist involved early! Do not burn any bridges and all will be well....:thumbup:
Click to expand...

Very true
 
seinfeld said:
The real issue here is access to care.

If the reimbursement was good then we, anesthesia, would make ourselves immediately available to perform the sedation. But since the reality is that the economics dont make it a convincing argument for us to go down to ED regularly we dont. This puts the ED docs and other providers, cardiologists, Ortho, looking for ways to get their patients what they need. At my institution propfol is restricted to anesthesia, so then the ED uses ketamine and etomidate. Unfortunately the worst outcomes i have seen with ED sedation have come when they use Versed and Fentanyl. At the current time most GI procedures are lucrative so we do them without hesitation.

So i guess my point is that there is ideal situations and reality. Ideally anesthesia would always perform the sedation but that would mean I would have to hire another DOC or CRNA to be available for this (or have to hold an OR while we went down to ED). Since the reimbursement would suck we would request the hospital to pony up some cash. That will never happen. So teach people how to use the drugs safely and when to ask for help.
Click to expand...

Well said. I have not been impressed with versed and fentanyl for procedural sedation either. The current state is exactly as you have outlined, that we are now calling Anesthesia for all sedations and I think it is overwhelming their service, increasing our wait times, and leading to suboptimal care for all. Just my opinion.
 
pgg said:
Is it time for this thread again? ;)

http://forums.studentdoctor.net/showthread.php?t=758889
http://forums.studentdoctor.net/showthread.php?t=782588


The facts as I see them:
  • The ED standard of care is not the same as our standard of care, particularly with regard to NPO guidelines. You're OK with a room air general anesthetic in a full stomach. We're not.
  • ICUs aren't full of ARDS patients who aspirated during reductions in the ED. For short procedures with no airway instrumentation, what you cowboys do doesn't appear to be especially risky. (I still wouldn't do it.)
  • ED physicians are certainly capable of managing an airway while sedating a patient.
  • Anesthesiologists have neither the time nor the inclination to come to the ED to do all of your sedations for you.
  • What you do with your license in your house ought to be regulated by your society. It's not really our place to boss you around.
All that said, if you ask a bunch of anesthesiologists about the proper way to sedate a non-NPO patient, we're going to tell you that the "ED way" isn't it.
Click to expand...

Nicely put! Unfortunately, currently where I work in DC, the hospital has made these drugs not available for use by anyone other than anesthesia for procedural sedation based on I believe ASA guidelines....
 
panetrain said:
The issue is to avoid apnea and any associated airway emergencies. The drug of choice for me would be small doses of ketamine (10-50mg) and midazolam (1-2mg). Ketamine avoids apnea and offers analgesia (no need for fentanyl). Small doses of midazolam (1-2mg) avoids recall of ketamine induced nightmares. During every sedation I perform, I always anticipate an emergent crash and possible burn. Have airway equipment and drugs drawn up (sux, atropine, epi) AT BEDSIDE AND READY to ROCK just in case.
Click to expand...

Agree entirely!
 
Members don't see this ad :)
ThymeLess said:
Well said. I have not been impressed with versed and fentanyl for procedural sedation either. The current state is exactly as you have outlined, that we are now calling Anesthesia for all sedations and I think it is overwhelming their service, increasing our wait times, and leading to suboptimal care for all. Just my opinion.
Click to expand...

Versed and fentanyl are fine for procedural sedation, and in the right hands, are probably safer than propofol for patients who are not NPO. My suspicion is that many are just too impatient to use Fent/Versed properly, which is one reason a lot of people want to use propofol with it's quick onset and emergence. Deep sedation should not be done on patients that aren't NPO. We don't do ER sedation at all, because those patients aren't going to meet our NPO requirements. We don't sedate GI cases if they're not NPO either, so why would we do it in the ER? If they require our expertise, they come to the OR.
 
jwk said:
Versed and fentanyl are fine for procedural sedation, and in the right hands, are probably safer than propofol for patients who are not NPO. My suspicion is that many are just too impatient to use Fent/Versed properly, which is one reason a lot of people want to use propofol with it's quick onset and emergence. Deep sedation should not be done on patients that aren't NPO. We don't do ER sedation at all, because those patients aren't going to meet our NPO requirements. We don't sedate GI cases if they're not NPO either, so why would we do it in the ER? If they require our expertise, they come to the OR.
Click to expand...

Good to hear this side of view. Do you take all the food bolus patients to the OR 24/7? and the patients who need a traction pin placed? elbow and shoulder reductions etc...I am impressed, and you're right by my choice of specialty I am in a rush and much prefer quick on quick off, but I hear what you are saying.
 
IN2B8R said:
I personally have no problems with ED docs using these drugs. But I will say this: "proceed at your own risk!" Full stomachs (which are the majority of your patients), difficult AWs and specific patient considerations, i.e., specific medical conditions, warrant an anesthesiologist's consult before you get started with any sedation. Reason? There is not a single anesthesiologist I know who likes to run to the ED and see a f*cked up AW that has been already mucked up by the ED staff. We all have to realize our limits: when you know that it is a bad airway and/or a risky patient, you should get the anesthesiologist involved early! Do not burn any bridges and all will be well....:thumbup:
Click to expand...

We do have guidelines on NPO status: http://www.acep.org/clinicalpolicies/

its is halfway down under sedation/analgesia policies

I think some misunderstand that we are just doing this stuff willy-nilly....
 
After reading that ED document I would say that when faced with a decision which has questionable evidence the ED society is ok with a rare event where as the ASA is shooting for zero events.
 
JackBauERfan said:
We do have guidelines on NPO status: http://www.acep.org/clinicalpolicies/

its is halfway down under sedation/analgesia policies

I think some misunderstand that we are just doing this stuff willy-nilly....
Click to expand...

Hmmm, it seems the guidelines have little objectivity, and essentially say that in the absence of any real data that practitioners should use their own judgment with regards to NPO status of patients, or lack thereof.

It also appears that the guidelines contradict themselves. They include a statement about being able to manage a level of sedation "1 level deeper" than that which is intended, and that because of that, the practitioner involved should be trained to handle that deeper level just in case. But the next deeper level of sedation from "deep sedation" is general anesthesia, a level which ED practitioners and nursing personnel are certainly not trained in, and therefor would seem to be inappropriate. That concept of a sedation continuum, from no sedation to general anesthesia, is what drives our hospital policy of no anesthesia drugs being available outside the OR.
 
ThymeLess said:
I am curious about what everyone's thoughts are on the use of propofol, ketamine, etomidate being used for sedation in the ER by EM attendings.

I am an EM attending and found these medications to be supremely helpful for orthopedic reductions, complex lacerations, endoscopy, etc. What is everyone's thoughts on this?

TL
Click to expand...

Etomidate and Propofol have a very thin line between sedation and GA...Most ER guys usually do GA and call it "sedation".

I dare say any good CA-2 is 95% better at airways than most ER attendings. I usually see scary and novice techniques in airway management down in the ER, even from senior residents and attendings, so I think you can guess my thoughts on using general anesthetics as "sedation".

As long as we're getting paid for our services, send em up to the OR, or have us come down to perform the sedation/GA in a timely fashion. It's the best thing for patient.
 
jwk said:
Versed and fentanyl are fine for procedural sedation, and in the right hands, are probably safer than propofol for patients who are not NPO. My suspicion is that many are just too impatient to use Fent/Versed properly, which is one reason a lot of people want to use propofol with it's quick onset and emergence. Deep sedation should not be done on patients that aren't NPO. We don't do ER sedation at all, because those patients aren't going to meet our NPO requirements. We don't sedate GI cases if they're not NPO either, so why would we do it in the ER? If they require our expertise, they come to the OR.
Click to expand...
Agree with the above told.

But, most of the times, ''non-trained to sedation/anesthesia'' personal would give a single dose of fentanyl and versed for a whole 40 minutes procedure... I've seen some radiologists that are not aware about fentanyl and versed's pharmacokinetics...
 
JackBauERfan said:
We do have guidelines on NPO status: http://www.acep.org/clinicalpolicies/

its is halfway down under sedation/analgesia policies

I think some misunderstand that we are just doing this stuff willy-nilly....
Click to expand...

All I can say about these guidelines are, THANK GOD the committee of MD's also includes at least one RN, MSN, CEN, CNA, COHN-S :laugh:
 
I see the use of pharmaceuticals falling into 3 categories.

1 - Those which are an intrinsic part of a specialty.

2 - Those which are not an intrinsic part of the specialty, but are a reasonable extension of the scope of practice.

3 - Those which the practitioner has no business administering/ prescribing.


For anesthesiologists, #1 is fairly obvious (anesthetics, pressors/ inotropes, paralytics etc). #2 would include things like perioperative management of basal insulin and insulin pumps, immunosuppressants for transplants, antibiotics. #3 would be things like oncologic agents and radioisotopes.


To me, propofol/ ketamine/ etomidate all fall into category 2 for ED physicians. Furthermore, I have a real issue with any specialty trying to define the scope of practice of another physician specialty (cough Ortho cough regional). If an emergency doc pursues additional training in administering these medications and the implications of doing do, more power to them. Heck, some of us allow nurses (CRNAs) to play with these drugs all the time.


Ideally, there would always be one MD administering these drugs and monitoring the patient while a second MD performs the procedure. In many cases, this is not practical and the decision should be left to the judgement of the MD. Administering them without the necessary skills and training to rescue the patient from inadvertent overdosage is malpractice.


For most docs, these drugs are clearly category 3, but I believe that they are category 2 for ER docs. I would rather be called sooner than later, but even better is to never be called at all.


- pod
 
I agree with all of this. As a physician, I don't really feel the need to try and restrict another physicians scope of practice. If the cowboys downstairs want to have at it, then more power to them. As far as I know their track record is pretty good. I do not want to go down there for this stuff, because I will do an RSI and tube the patient. And I don't want them sending patients up to the OR for the same thing. So they can have at it as far as I am concerned.


pgg said:
Is it time for this thread again? ;)

http://forums.studentdoctor.net/showthread.php?t=758889
http://forums.studentdoctor.net/showthread.php?t=782588


The facts as I see them:
  • The ED standard of care is not the same as our standard of care, particularly with regard to NPO guidelines. You're OK with a room air general anesthetic in a full stomach. We're not.
  • ICUs aren't full of ARDS patients who aspirated during reductions in the ED. For short procedures with no airway instrumentation, what you cowboys do doesn't appear to be especially risky. (I still wouldn't do it.)
  • ED physicians are certainly capable of managing an airway while sedating a patient.
  • Anesthesiologists have neither the time nor the inclination to come to the ED to do all of your sedations for you.
  • What you do with your license in your house ought to be regulated by your society. It's not really our place to boss you around.
All that said, if you ask a bunch of anesthesiologists about the proper way to sedate a non-NPO patient, we're going to tell you that the "ED way" isn't it.
Click to expand...
 
periopdoc said:
I see the use of pharmaceuticals falling into 3 categories.

1 - Those which are an intrinsic part of a specialty.

2 - Those which are not an intrinsic part of the specialty, but are a reasonable extension of the scope of practice.

3 - Those which the practitioner has no business administering/ prescribing
Click to expand...
Interesting.
 
Another ER attending here with my two cents. I think these drugs are fine in the hands of properly trained docs. I have worked in ER's with all residency trained docs and in some with board certified family medicine trained docs and the difference is huge. ER trained docs manage airways on a regular basis and if there is a complication with any of these meds we are fully trained to handle it.
My preference is propofol rather than any of the other meds. It is quick on and off and does a good job of relaxation. With some of you talking about the ER using GA with these meds are you assuming we are doing an infusion instead of a bolus only?
 
cowbydoc said:
Another ER attending here with my two cents. I think these drugs are fine in the hands of properly trained docs. I have worked in ER's with all residency trained docs and in some with board certified family medicine trained docs and the difference is huge. ER trained docs manage airways on a regular basis and if there is a complication with any of these meds we are fully trained to handle it.
My preference is propofol rather than any of the other meds. It is quick on and off and does a good job of relaxation. With some of you talking about the ER using GA with these meds are you assuming we are doing an infusion instead of a bolus only?
Click to expand...

Do you think it's only GA if it's an infusion?
 
Coastie said:
Do you think it's only GA if it's an infusion?
Click to expand...
Nope, it just seems that some people assume we cannot titrate minimal doses of some medications to achieve moderate but not deep sedation and I was wondering about the assumptions some may have made.
 
cowbydoc said:
Nope, it just seems that some people assume we cannot titrate minimal doses of some medications to achieve moderate but not deep sedation and I was wondering about the assumptions some may have made.
Click to expand...

cowboydoc: I hate to admit it, but Coastie's concern is legit.

Rarely do I encounter residents in the ED who are familiar with the distinctions between moderate and deep sedation...nor the thin line between deep sedation and general anesthesia.

And rarely do I ever actually want moderate sedation...If I am reaching for propofol/etomidate/etc, I am looking for deep sedation, if not general anesthesia.

In these forums, we should call it like it is.

OTOH, I have only minimal concerns about transient GA for procedural sedation without an RSI in properly trained hands (and appropriately selected patients) - and the literature supports me on that - and am a firm believer in applying anesthesia's guidlines to the OR and EM's guidlines to the ED.

HH

(disclosure: I am EM, not anesthesia)
 
Last edited:
cowbydoc said:
Nope, it just seems that some people assume we cannot titrate minimal doses of some medications to achieve moderate but not deep sedation and I was wondering about the assumptions some may have made.
Click to expand...


Those of us on this forum making said assumptions are probably doing so on the basis of prior experience with ER physicians. It may not be YOU, and it may not be YOUR E.D., but it happens.

Don't take it personally. There's another thread involving airway management and depth of anesthesia. There was at least one anesthesia provider who seemed to misinterpret definitions of sedation and GA.

We appreciate the input from providers of other disciplines, but the bottom line is this is an anesthesia forum, so we tend to be suspicious of folks who don't use our drugs as often as we do. We've been treated the same in your forum.
 
No offense taken. I think the overall message is that these drugs should be treated with great caution and are not just cool toys to use. But, they do work and work very well and in trained hands are very useful. The problem most ED docs have is the time of onset and the duration of the versed/fentanyl combo when compared with propofol and etomidate. It not only ties me up but also a nurse for much longer which can slog the whole department down. FWIW it takes me about 15 minutes to set up for a 15 second procedure so I know that I have every tool I need if something bad were to happen.

BTW the reason I am trolling around here is I am burned out of ER and am switching to anesthesia with my residency starting this summer, but that is a whole different thread. This is just a topic that interests me and I wanted to throw my two cents in.
 
cowbydoc said:
BTW the reason I am trolling around here is I am burned out of ER and am switching to anesthesia with my residency starting this summer, but that is a whole different thread. This is just a topic that interests me and I wanted to throw my two cents in.
Click to expand...

It would be fascinating to see your take on this issue 3 years hence.

- pod
 
cowbydoc said:
No offense taken. I think the overall message is that these drugs should be treated with great caution and are not just cool toys to use. But, they do work and work very well and in trained hands are very useful. The problem most ED docs have is the time of onset and the duration of the versed/fentanyl combo when compared with propofol and etomidate. It not only ties me up but also a nurse for much longer which can slog the whole department down. FWIW it takes me about 15 minutes to set up for a 15 second procedure so I know that I have every tool I need if something bad were to happen.

BTW the reason I am trolling around here is I am burned out of ER and am switching to anesthesia with my residency starting this summer, but that is a whole different thread. This is just a topic that interests me and I wanted to throw my two cents in.
Click to expand...

Switching over? Wow.

Could you please elaborate? I have some anesthesia friends considering a switch to ER....


And I second what periopdoc said above.
 
Planktonmd said:
ER guys should not mess with anesthetics they don't understand.
Click to expand...

_______ should not mess with anesthetics they don't understand.

"ER guys", anesthesiologists, and certainly nurses (CRNAs)...I am pretty sure the title (among physicians) should not define who should use what meds...rather, "understanding" is what matters...

Thanks for understanding,

HH
 
Hamhock said:
_______ should not mess with anesthetics they don't understand.

"ER guys", anesthesiologists, and certainly nurses (CRNAs)...I am pretty sure the title (among physicians) should not define who should use what meds...rather, "understanding" is what matters...

Thanks for understanding,

HH
Click to expand...

So why don't you tell us what your understanding of propofol is.
 
proman said:
So why don't you tell us what your understanding of propofol is.
Click to expand...

I know enough not to hand to unsupervised nurses.

HH

I probably should not have responded to Plankton's antagonism, but I couldn't help myself. Previously, I think this was a somewhat educational thread. Perhaps we should return to that angle? I'll keep my mouth shut.
 
proman said:
So why don't you tell us what your understanding of propofol is.
Click to expand...

I would be excited to learn more if there is something that is important to my patients. Here is what I know off the top of my head.

My current understanding is that propofol is a centrally acting anesthetic without any analgesic effect and may need some opiate adjunctive medication.

For proper use, it should be administered by the physician in the setting of continuous cardiopulmonary monitoring including end tidal CO2 monitoring, advanced airway equipment at bedside (fiberoptics, bougie, LMA, etc). The person managing anesthesia should be distinct from the proceduralist (as with all procedural sedation).

It has a very short (~minute) half life, and is best with a bolus start and subsequent drip or repeat small boluses to maintain necessary level of anesthesia. If used for a noxious procedure such as orthopedic reduction, after completion of the noxious stimuli, sedation may suddenly be far deeper than previously achieved with the same dosages. The doses are weight based and differ for procedural sedation, rapid sequence intubation, and for general anesthesia.

Propofol is lipid soluble and can linger in the tissues of those with large amounts of adipose. It can cause lactic acidosis as well I believe.

The major side effects of proposal include hypotension (secondary to peripheral vasodilation), loss of respiratory drive and protective airway reflexes with higher doses. Regarding the side effects, hypotension has some correlation with the rate of infusion, and can be countered by small amounts of phenylephrine if necessary.

Lastly, propofol also has some antiepileptic qualities and can be an excellent adjunct to subclinical status patient.

I apologize, I am sure my understanding seems juvenile to anesthesiologists, just as my understanding of orthopedics is no where near an orthopedists etc. I want to learn more if there are key aspects that I should know.

Thank you,
TL

PS: I use the word "anesthesia," because even what I call procedural sedation is simply a level on the spectrum of anesthesia.
 
ThymeLess said:
For proper use, it should be administered by the physician in the setting of continuous cardiopulmonary monitoring including end tidal CO2 monitoring, advanced airway equipment at bedside (fiberoptics, bougie, LMA, etc). The person managing anesthesia should be distinct from the proceduralist (as with all procedural sedation).
Click to expand...

Great. You likely are one of the safe users of the drug. Problem is that you're not very common. In residency I went to the ED to use propofol to help reduce a difficult shoulder dislocation. After an appropriate pre-anesthetic evaluation, NPO status and monitoring, I bolused propofol. EM attending goes, "In my other hospital, I can use propofol for sedation just like you do." I told her I had induced general anesthesia just like she does. But the key point, which several people have stated, is that there must be a dedicated trained person monitoring the patient. One guy can't do it all safely. Is that your practice?
 
ThymeLess said:
For proper use, it should be administered by the physician in the setting of continuous cardiopulmonary monitoring including end tidal CO2 monitoring, advanced airway equipment at bedside (fiberoptics, bougie, LMA, etc). The person managing anesthesia should be distinct from the proceduralist (as with all procedural sedation).
Click to expand...

So you're telling me that one physician does the procedure while another physician administers propofol?

Otherwise, you have a nurse administering the propofol (illegal in many states) while you direct him/her while you're also performing the procedure, thus diverting your attention away from actually managing the sedation. But no offense, this is the exact same problem I have with RN-administered propofol in the GI suite directed by a gastroenterologist.
 
Ketamine is good for procedural sedation in the ED. It causes minimal respiratory depression and provides analgesia. When I rotated in the ED as an intern they used for setting hips and shoulders. Worked great. I hate etomidate unless the pt. is unstable, however, in my experience it usually does not cause apnea and so may be safer than propofol in untrained hands. Propofol can lead you down a very slippery slope and I agree with most others on here that it should not be used except by anesthesia providers. The other drug that concerns me in the ED is vecuronium/rocuronium. I have been to the ED on several occasions to intubate a pt. and the nurse/ED attending keeps asking if they can give the vecuronium yet. No you can't give the vec yet!!! Please step away from the vecuronium, I am pretty sure you know less how to use that than you do propofol. Got a pt. in the ICU one night in transfer from OSH. Pt. got 2mg versed and 10mg vecuronium for intubation and then transfered. BP's were in the 200's on arrival. Upon reading this note we immediately gave some sedation and BP's immediately normalized. SCARY!!!!! I admire EM docs because I could never do what they do, but sometimes people have to admit what they don't know and ask for help (including me).
 
ThymeLess said:
I would be excited to learn more if there is something that is important to my patients. Here is what I know off the top of my head.

My current understanding is that propofol is a centrally acting anesthetic without any analgesic effect and may need some opiate adjunctive medication.

For proper use, it should be administered by the physician in the setting of continuous cardiopulmonary monitoring including end tidal CO2 monitoring, advanced airway equipment at bedside (fiberoptics, bougie, LMA, etc). The person managing anesthesia should be distinct from the proceduralist (as with all procedural sedation).

It has a very short (~minute) half life, and is best with a bolus start and subsequent drip or repeat small boluses to maintain necessary level of anesthesia. If used for a noxious procedure such as orthopedic reduction, after completion of the noxious stimuli, sedation may suddenly be far deeper than previously achieved with the same dosages. The doses are weight based and differ for procedural sedation, rapid sequence intubation, and for general anesthesia.

Propofol is lipid soluble and can linger in the tissues of those with large amounts of adipose. It can cause lactic acidosis as well I believe.

The major side effects of proposal include hypotension (secondary to peripheral vasodilation), loss of respiratory drive and protective airway reflexes with higher doses. Regarding the side effects, hypotension has some correlation with the rate of infusion, and can be countered by small amounts of phenylephrine if necessary.

Lastly, propofol also has some antiepileptic qualities and can be an excellent adjunct to subclinical status patient.

I apologize, I am sure my understanding seems juvenile to anesthesiologists, just as my understanding of orthopedics is no where near an orthopedists etc. I want to learn more if there are key aspects that I should know.

Thank you,
TL

PS: I use the word "anesthesia," because even what I call procedural sedation is simply a level on the spectrum of anesthesia.
Click to expand...

I like you since you are at least willing to learn, which, I guess, says something about your character. You have mentioned relevant characteristics of the drug. What a consultant anesthesiologist must also know are the relevant medical/surgical characteristics of the patient which also have a bearing on the way propofol (or any other drug, for that matter) is utilized. Understanding the pharmacodynamic/pharmacokinectic concepts is important, but a contextual understanding is just as important. That, in all seriousness, is part of an anesthesiology residency. Such an understanding also distinguishes you from every other monkey who is capable of pushing the plunger of a syringe!
 
I was in the main OR today and heard we now have Propofol that is kept in a refrigerator and is good for 12 hours after removing it. It comes in a prefilled 20 ml syringe, but since it is in a refrigerator I'm guessing it is altered locally. I don't know how. It was too busy/long of a day for me to quiz the pharmacist. I'll try to find out tomorrow. It seemed to behave like normal Propofol.

Just thought I would toss that out there since we are talking about Propofol, and to try to get this thread a little more clinical again.
 
proman said:
Great. You likely are one of the safe users of the drug. Problem is that you're not very common. In residency I went to the ED to use propofol to help reduce a difficult shoulder dislocation. After an appropriate pre-anesthetic evaluation, NPO status and monitoring, I bolused propofol. EM attending goes, "In my other hospital, I can use propofol for sedation just like you do." I told her I had induced general anesthesia just like she does. But the key point, which several people have stated, is that there must be a dedicated trained person monitoring the patient. One guy can't do it all safely. Is that your practice?
Click to expand...

I agree entirely. Yup, I was fortunate to have great teachers who felt just like you've outlined, it is essential that a provider be designated only for the sedation and not involved or distracted by the procedure being undertaken.
 
jwk said:
So you're telling me that one physician does the procedure while another physician administers propofol?

Otherwise, you have a nurse administering the propofol (illegal in many states) while you direct him/her while you're also performing the procedure, thus diverting your attention away from actually managing the sedation. But no offense, this is the exact same problem I have with RN-administered propofol in the GI suite directed by a gastroenterologist.
Click to expand...

No, where I did my residency and learned my methods for procedural sedation, it was hospital policy that a provider be designated for the sedation (or anesthesia) alone.
 
rsgillmd said:
I was in the main OR today and heard we now have Propofol that is kept in a refrigerator and is good for 12 hours after removing it. It comes in a prefilled 20 ml syringe, but since it is in a refrigerator I'm guessing it is altered locally. I don't know how. It was too busy/long of a day for me to quiz the pharmacist. I'll try to find out tomorrow. It seemed to behave like normal Propofol.

Just thought I would toss that out there since we are talking about Propofol, and to try to get this thread a little more clinical again.
Click to expand...

The syringes are probably just filled under the sterile hood.
 
:rolleyes:
You don't know what you don't know and an internet forum is not the right place to teach you anesthesia.

Hamhock said:
_______ should not mess with anesthetics they don't understand.

"ER guys", anesthesiologists, and certainly nurses (CRNAs)...I am pretty sure the title (among physicians) should not define who should use what meds...rather, "understanding" is what matters...

Thanks for understanding,

HH
Click to expand...
 
Gimlet said:
The syringes are probably just filled under the sterile hood.
Click to expand...

I asked our pharmacist today. She says they come from Pharmedium and must be kept refrigerated. When we get them, we take them from a refrigerator but obviously keep it at room temp in the OR.

I'll have to call Pharmedium when I get a chance and ask. If simple refrigeration is good enough, why not just refrigerate the regular propofol vials?

I have to also look at a regular vial and see what temp conditions it is recommended to store them at.
 
You must log in or register to reply here.
Next unread thread

Similar threads

P
White House Medical Unit ordering fentanyl, ketamine, morphine
Replies
14
Views
1K
Arantius
A
O
Good research question on ketamine
Replies
9
Views
1K
woopedazz
woopedazz
U
Propofol waste
2
Replies
50
Views
3K
Gas
G
Ronin786
Remimazolam vs Propofol
Replies
24
Views
2K
OTCAwesome
OTCAwesome
I
Stage 2 with propofol infusion?
Replies
10
Views
2K
coffeebythelake
coffeebythelake
Top