Michael Jackson abusing propofol?

[narcusprince]

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Their are multiple issues present brought forth with the Michael Jackson case. Currently their is a general sense from the public that we as anesthesiologist put people to sleep. When thats NOT what we are doing they are under Anesthesia, NOT sleeping. As a lowly CA-1, I am trying my best to not use the term SLEEP to my patients because its oversimplifying a complex state. Currently their is way too much minimizing what we as anesthesiologist do by using such crude and simple terms like sleep. My understanding is that an anesthesiologist was running the infusions of propofol to keep michael sedated. Why was an anesthesiologist giving Michael Propofol for sleep do not know but I can make a good gue$$.

 

[NateintheED]

As a CA-3 and having done hundreds of MAC cases using propofol, precedex, ketamine, you name it, I'm still learning the art of sedation and the great variabilities you will encounter b/w patients, doses, boluses, infusion rates, apneic threshold, etc. Where I agree with my anesthesia colleagues, is ER docs and any other doc will never accumulate the experience and feel for propofol and can run into trouble they wouldn't have imagined. Is this fracture reduction NPO? Are you sedating with propofol or are you inducing GA with loss of airway reflexes? There's a host of problems that accompany this drug that you need to be prepared for and the best person for that job is an anesthesiologist.

Do you use more propofol than an EM doc? Sure. Nobody argues that. BUT...

-I am also capable of telling time, and assesing if someone has been NPO. If not, then I'll wait an appropriate interval before sedating.

-My goal is to sedate with propfol, not get into GA. BUT we both know this is a spectrum. Might I briefly stray into GA-level sedation? Maybe, after all it is a spectrum, but I know how to manage that. See below.

-On complications of propofol: Correct me if I'm wrong, but the ones to worry about are apnea/hypoxia, potential airway compromise, hypotension, and maybe a VERY rare anaphylaxis. If you are asserting that a residency-traind emergency physician cannot monior for and manage these conditions, then you are very uninformed about our training and practice. I manage all of these on a frequent basis, sometimes all at once. And I would argue that managing them as known side effects of propofol is much easier than as the presentation of a hypotensive, hypoxic, obtunded patient with, say, septic shock or abdominal catatrophe. At least in the setting of sedation, when the drug goes away, so do the adverse effects.

 

[drccw]

Do you use more propofol than an EM doc? Sure. Nobody argues that. BUT...

-I am also capable of telling time, and assesing if someone has been NPO. If not, then I'll wait an appropriate interval before sedating.

-My goal is to sedate with propfol, not get into GA. BUT we both know this is a spectrum. Might I briefly stray into GA-level sedation? Maybe, after all it is a spectrum, but I know how to manage that. See below.

-On complications of propofol: Correct me if I'm wrong, but the ones to worry about are apnea/hypoxia, potential airway compromise, hypotension, and maybe a VERY rare anaphylaxis. If you are asserting that a residency-traind emergency physician cannot monior for and manage these conditions, then you are very uninformed about our training and practice. I manage all of these on a frequent basis, sometimes all at once. And I would argue that managing them as known side effects of propofol is much easier than as the presentation of a hypotensive, hypoxic, obtunded patient with, say, septic shock or abdominal catatrophe. At least in the setting of sedation, when the drug goes away, so do the adverse effects.

I have no problem with EM physicians performing sedation with the appropriate agent in the appropriate patient. The problems is that the line between sedation and GA isn't absolute, and I do feel that many EM physicians do not understand said line. Nor do I believe they fully understand who the appropriate patient is. Or the appropriate agent. I've had EM docs tell me that ketamine is fine in the patient with a full stomach because it "protects airway reflexes". And what's the dose of etomidate for sedation? 0.2 mg/kg... So I think EM docs and nurses can perform SEDATION in the appropriate patient with the appropriate agent... However, I find that when I am wondering around the ER they aren't performing sedation but performing GAWAC. (General anesthesia without airway control).

 

[paiute]

as long as proper staff and equipment was available at the house and standard monitoring used. tough to argue that. Do you need a hospital to use propofol safely?

doesn't California prohibit GA except in a licensed hospital or surgery center?

 

[maceo]

Do you use more propofol than an EM doc? Sure. Nobody argues that. BUT...

-I am also capable of telling time, and assesing if someone has been NPO. If not, then I'll wait an appropriate interval before sedating.

-My goal is to sedate with propfol, not get into GA. BUT we both know this is a spectrum. Might I briefly stray into GA-level sedation? Maybe, after all it is a spectrum, but I know how to manage that. See below.

-On complications of propofol: Correct me if I'm wrong, but the ones to worry about are apnea/hypoxia, potential airway compromise, hypotension, and maybe a VERY rare anaphylaxis. If you are asserting that a residency-traind emergency physician cannot monior for and manage these conditions, then you are very uninformed about our training and practice. I manage all of these on a frequent basis, sometimes all at once. And I would argue that managing them as known side effects of propofol is much easier than as the presentation of a hypotensive, hypoxic, obtunded patient with, say, septic shock or abdominal catatrophe. At least in the setting of sedation, when the drug goes away, so do the adverse effects.

hey nate

there is no sedation with propofol. its either GA (deep sedation) or awake. anything inbetween the patients are doing the shimmy, talking smack, just completely disinhibited because there in the in between stage. The safest way to use propofol, in my opinion is patients completely knocked out. ( breathing spontaneously of course.

why would an er doc want to sedate patients down there. dont you have other stuff to do? The only way i would sanction it. is if that was the only thing you were doing and NOTHING else. No phone calls, no beeper, no handling other patients. That was the ONLY Thing you would be doing.

 

[Planktonmd]

-On complications of propofol: Correct me if I'm wrong, but the ones to worry about are apnea/hypoxia, potential airway compromise, hypotension, and maybe a VERY rare anaphylaxis. If you are asserting that a residency-traind emergency physician cannot monior for and manage these conditions, then you are very uninformed about our training and practice. I manage all of these on a frequent basis, sometimes all at once. And I would argue that managing them as known side effects of propofol is much easier than as the presentation of a hypotensive, hypoxic, obtunded patient with, say, septic shock or abdominal catatrophe. At least in the setting of sedation, when the drug goes away, so do the adverse effects.

You can not compare managing an emergency to providing an elective anesthetic to a patient to allow a surgeon to perform a procedure.
In an emergency the main goal is for the patient to make it alive, while in providing anesthesia the main focus is providing proper anesthesia for the procedure and the most comfortable conditions for the patient and the surgeon while minimizing side effects and preventing complications.
The expectations are totally different.
Comparing an emergency to the administration of anesthesia is like comparing what EMS do to what an ER physician does.

 

[Coastie]

he shoulda used precedex for his naps..probably would have been better off.

 

[NateintheED]

hey nate

there is no sedation with propofol. its either GA (deep sedation) or awake. anything inbetween the patients are doing the shimmy, talking smack, just completely disinhibited because there in the in between stage. The safest way to use propofol, in my opinion is patients completely knocked out. ( breathing spontaneously of course.

why would an er doc want to sedate patients down there. dont you have other stuff to do? The only way i would sanction it. is if that was the only thing you were doing and NOTHING else. No phone calls, no beeper, no handling other patients. That was the ONLY Thing you would be doing.

Mace,
If I’m reading your post correctly, it seems what we have here is more a matter of semantics than anything. It seems that you draw no distinction between deep sedation and GA. To me, in deep sedation, the patient maintains airway reflexes and respiratory drive, and may still have some response to painful stimuli, maybe not much, but some sort of response. I can and have achieved that with propofol.

As far as why I would want to do sedation in the ED… First, yes, I almost always have other things I could be doing. BUT, I do sedation because it’s the best thing for the patient. Things like simple closed fracture reductions or large but otherwise uncomplicated cutaneous abscesses just can’t be locally anesthetized, and gen surg or ortho would laugh at me if I asked them to take these to the OR. In many community places, they won’t even come in for these. Then there are things like facial lacs in kids that only need a few sutures, but need the kid to hold still. Also not going the OR. And sometimes the patient just needs a little relaxation or amnesia, like in a quick dislocation reduction or cardioversion. Finally, most places don’t have an anesthesia provider available to come down and do these sedations – they’re either not in house at night, or doing cases that really do require GA during the day.

And when I’m doing a sedation, that is the only thing I’m doing. Maybe I’ll answer a quick question about another patient, but I’m not on the phone, calling consultants, or anything like that. The only time I would leave the room would be if another patient is actively trying to die, in which case I’d stop the sedation. Then once the procedure is over, its just like PACU – I leave them with the 1:1 nurse to wake up.

 

[NateintheED]

You can not compare managing an emergency to providing an elective anesthetic to a patient to allow a surgeon to perform a procedure.
In an emergency the main goal is for the patient to make it alive, while in providing anesthesia the main focus is providing proper anesthesia for the procedure and the most comfortable conditions for the patient and the surgeon while minimizing side effects and preventing complications.
The expectations are totally different.
Comparing an emergency to the administration of anesthesia is like comparing what EMS do to what an ER physician does.

You’re right – there is no comparison. But I think you missed the point of my post. I was not trying to compare managing an emergently ill patient to providing elective anesthesia. The point I was making was that I am perfectly capable of managing the physiologic abnormalities that are the primary adverse effects of propofol. And I do it routinely in patients much sicker than the typical patient undergoing procedural sedation.

 

[GassiusClay]

99% of the time, things may be fine. It's that other 1% of the time that most of us are worried about...

That 1%. How about an ER doc getting a hold of propofol and inducing basically a GA and then couldn't handle the airway? Gonna be a big lawsuit. Pushing propofol is not that simple since comorbidities can affect the outcome (thin vs fat folks, good EF vs poor EF, etc).

 

[dhb]

To me, in deep sedation, the patient maintains airway reflexes and respiratory drive, and may still have some response to painful stimuli, maybe not much.

That's a pretty good definition of GA ie you're at 1 mac of agent right there.
I think everybody will agree that it would be impossible to have an anesthesia provider for every procedures that take place in every ER, and sometimes you got to do what you gotta do. But it doesn't make it the absolute best for the patient to undergo a relatively uncontrolled GA in the ER.
Anesthesia has become very safe but all it take is one time.
I agree with the previous posters that inducing a healthy patient has very little to do with resuscitating a very sick one.

 

[leviathan]

That is true but every study shows that the highest chance of sucess is with defibrillation and maybe with med. So could 2 min of CPR be justified - yes- but 30 is totally out of protocol.

Why even do 2 minutes? You need an ambulance coming with a defib + ACLS meds immediately, not in 30 minutes, not in 2 minutes. If the ambulance was there at the beginning of resuscitation, then a 2 minute cycle of CPR might be warranted to "prime" the heart, but that's a completely different ballpark.

 

[maceo]

That's a pretty good definition of GA ie you're at 1 mac of agent right there.
I think everybody will agree that it would be impossible to have an anesthesia provider for every procedures that take place in every ER, and sometimes you got to do what you gotta do. But it doesn't make it the absolute best for the patient to undergo a relatively uncontrolled GA in the ER.
Anesthesia has become very safe but all it take is one time.
I agree with the previous posters that inducing a healthy patient has very little to do with resuscitating a very sick one.

anesthesia hasnt become safer... the providers have gotten better. There are still the same risks as before but we understand them better. Now everyone thinks its easy because not as many people are dying. But i guarantee you, there are lapses in judgement all the time and healthy people do die. ESPECIALLY with propofol without being trained. case in point michael jackson. The only other 2 people that I have heard die in the past few years under anesthesia have both been sedated with propofol for upper endoscopy. It aint that easy

and NATE. how many people who just dislocated a bone come to the ER appropriately fasted. I bet less then 10 percent in which case you shouldnt be doing this. I dont have an objection to you doing this but I would say you have to spend 3 months with us to be certified to do it

 

[dhb]

the providers have gotten better.

That too but don't tell me that sevo and prop aren't safer then halo and pent.

 

[Planktonmd]

You’re right – there is no comparison. But I think you missed the point of my post. I was not trying to compare managing an emergently ill patient to providing elective anesthesia. The point I was making was that I am perfectly capable of managing the physiologic abnormalities that are the primary adverse effects of propofol. And I do it routinely in patients much sicker than the typical patient undergoing procedural sedation.

I actually think you missed the point of what I was trying to say:
The fact that you can (hopefully) manage hypotension, hypoxia and altered mental status in emergency room patients does not mean you can give anesthesia because it is not only about being able to treat complications it's about preventing complications and doing the right anesthetic for the procedure, the patient and the surgeon.
I don't expect you to fully understand what I am trying to tell you here but trust me on this one: It's more than just being able to treat complications.
And once you decide to become an anesthesia provider you should be held to the same standards and expectations that apply to other anesthesia providers.
Which means you will be expected to understand and apply what the majority of anesthesia providers consider safe and appropriate care and in order to know what that is you need to have the same training and education, and since you obviously don't, then if you make a mistake you will be crucified.
Is that too complicated??

 

[DreamMachine]

To me, in deep sedation, the patient maintains airway reflexes and respiratory drive, and may still have some response to painful stimuli, maybe not much, but some sort of response. I can and have achieved that with propofol.

With that level of sedation, don't be too confident that you are maintaining airway reflexes.

 

[NateintheED]

I actually think you missed the point of what I was trying to say:
The fact that you can (hopefully) manage hypotension, hypoxia and altered mental status in emergency room patients does not mean you can give anesthesia because it is not only about being able to treat complications it's about preventing complications and doing the right anesthetic for the procedure, the patient and the surgeon.
I don't expect you to fully understand what I am trying to tell you here but trust me on this one: It's more than just being able to treat complications.
And once you decide to become an anesthesia provider you should be held to the same standards and expectations that apply to other anesthesia providers.
Which means you will be expected to understand and apply what the majority of anesthesia providers consider safe and appropriate care and in order to know what that is you need to have the same training and education, and since you obviously don't, then if you make a mistake you will be crucified.
Is that too complicated??

I completely agree – its definitely not only about being able to treat the complications. Come on, nobody goes looking for them, anesthesia provider or emergency physician. BUT that is one reason that anesthesia providers cite that Emergency Physicians shouldn’t do sedation. I’m sorry – that argument doesn’t hold water.

As far as preventing said complications, what makes you think I can't pick the right drug for the procedure, patient and surgeon, especially from the small number of agents I have to choose from? By my count, I have about 5 drugs to choose from, depending on the institution, plus about 4 opiates that I use routinely. Do I need to do an anesthesia residency to know 9-10 drugs?

Mace – You’re right – many of these patients have not been NPO, especially the kids with fractures. If possible I, can, will, and do hold them in the ER for 3-4 hours until their stomachs are empty before I sedate. Dislocations are slightly different animals though – the longer I sit on it, the more the muscles spasm, and the harder its going to be to reduce, which takes some of the “electiveness”, if you will, out of the equation. If I can do a quick sedation with something relatively non-emetogenic, fix the problem and take the patient out of pain, then I’m going to do that. I know you take people with full stomachs to the OR. Granted, you intubate them once you’re there, but if the procedure is short, isn’t there still something in their stomach when you extubate them?

And as far as time spent with you to be qualified to do sedations, first see above regarding the limited number of agents available to me. And I would have loved if the anesthesia department I rotated with as a resident would’ve included some instruction on sedation as part of the rotation curriculum. In contrast, I was largely ignored and had to really push to get any tubes (and even then didn’t get to use anything but a plain old laryngoscope or place a plain LMA) at all while I was with them. There are definitely not 3 months available in residency, and even more definitely not in post-residency practice to do what you advocate.

 

[drccw]

I completely agree – its definitely not only about being able to treat the complications. Come on, nobody goes looking for them, anesthesia provider or emergency physician. BUT that is one reason that anesthesia providers cite that Emergency Physicians shouldn’t do sedation. I’m sorry – that argument doesn’t hold water.

As far as preventing said complications, what makes you think I can't pick the right drug for the procedure, patient and surgeon, especially from the small number of agents I have to choose from? By my count, I have about 5 drugs to choose from, depending on the institution, plus about 4 opiates that I use routinely. Do I need to do an anesthesia residency to know 9-10 drugs?

Mace – You’re right – many of these patients have not been NPO, especially the kids with fractures. If possible I, can, will, and do hold them in the ER for 3-4 hours until their stomachs are empty before I sedate. Dislocations are slightly different animals though – the longer I sit on it, the more the muscles spasm, and the harder its going to be to reduce, which takes some of the “electiveness”, if you will, out of the equation. If I can do a quick sedation with something relatively non-emetogenic, fix the problem and take the patient out of pain, then I’m going to do that. I know you take people with full stomachs to the OR. Granted, you intubate them once you’re there, but if the procedure is short, isn’t there still something in their stomach when you extubate them?

And as far as time spent with you to be qualified to do sedations, first see above regarding the limited number of agents available to me. And I would have loved if the anesthesia department I rotated with as a resident would’ve included some instruction on sedation as part of the rotation curriculum. In contrast, I was largely ignored and had to really push to get any tubes (and even then didn’t get to use anything but a plain old laryngoscope or place a plain LMA) at all while I was with them. There are definitely not 3 months available in residency, and even more definitely not in post-residency practice to do what you advocate.

This post is a good reason why I argue EM docs should not be providing sedation. It's because they lack an understanding of the potential complications-> of which I think most anesthesiologists would maintain it's aspiration. Apnea- isn't a huge deal (unless it's unrecognized)

it doesn't matter if you wait 3-4 hours after a fracture. They are still an aspiration risk.

http://www.ncbi.nlm.nih.gov/pubmed/2802116?dopt=Abstract

and it doesnt matter if you use something that isn't emetogenic. The danger period for aspiration is when you take away airway reflexes. That's why full stomachs get a RSI. Most providers will evacuate the stomach after induction and still perform an awake extubation (after airway reflexes have returned).

drccw

PS- we have EM residents rotate through our OR. I wish some had expressed a desire in sedation. Most don't express a desire in airway management. They come in after induction and state that they are " here for the tube", after which I kick them out the room and tell them to come back when they are ready to learn about airway management. Oh and please, most of them can't be botherered with a simple LMA insertion. Well let me tell you- proper airway management saves lives, not a tube. That includes BMV and LMA insertion.

 

[Planktonmd]

As far as preventing said complications, what makes you think I can't pick the right drug for the procedure, patient and surgeon, especially from the small number of agents I have to choose from? By my count, I have about 5 drugs to choose from, depending on the institution, plus about 4 opiates that I use routinely. Do I need to do an anesthesia residency to know 9-10 drugs?

Is that what they are teaching you in EM residency these days?
Are you really being told that the practice of anesthesia is knowing a few medications?
If that's the case then it is not your fault but the fault of your mentors who are misleading you for obvious political reasons.
Using your logic I can say: Do I need to do EM residency to know how to triage patients and call consultants which is about 95% of what you do in the ER?
If you think about what you eventually will be doing when you finish residency it really does not require medical education, all you need is to classify the patients in categories based on symptoms and then follow concrete protocols to manage them and call a specialist to take over the care.
You don't need more than a high school diploma to do that.

 

[Bertelman]

And as far as time spent with you to be qualified to do sedations, first see above regarding the limited number of agents available to me. And I would have loved if the anesthesia department I rotated with as a resident would’ve included some instruction on sedation as part of the rotation curriculum. In contrast, I was largely ignored and had to really push to get any tubes (and even then didn’t get to use anything but a plain old laryngoscope or place a plain LMA) at all while I was with them. There are definitely not 3 months available in residency, and even more definitely not in post-residency practice to do what you advocate.

Might I suggest extending your residency? 3 years is the shortest residency on the books.

 

[Gern Blansten]

All you have to do is know 9 drugs to be able to be qualified as an anesthesiologist? That is rich.
I have little regard for these types who stick their chest out and can be heard talking down to others about how things will occur "in my emergency department!" The schtick gets old pretty quick.

 

[mountaingastro]

this will keep propofol from being approved for use by non-anesthesiologists as the public will be scared of it now

that is a good thing

Interesting posts...

It seems that there must be an incredible dearth of scientific data on your side supporting the anesthesiologist guild's "restriction" of propofol use in some states (via nurse practice acts) and facilities (via credentialing) to anesthesia providers.

Until now, the objections to nonanesthesia propofol use I see cited here have been largely experiential or spiritual in nature (I believe this, my teacher told me, I saw this once in the GI lab...), and those professing these beliefs always completely dismiss substantial data showing that this drug is being used safely and effectively by nonanesthesiologists and their RNs (when both the physician and nurse are trained to do so, for moderate-deep procedural sedation) all over the world.

Fabulous! Now, you can additionally point to an unfortunate public event involving the clear misuse-abuse of this drug as further "evidence" supporting your guild's protective turf war. Incredibly relevant!

 

[DreamMachine]

Interesting posts...

It seems that there must be an incredible dearth of scientific data on your side supporting the anesthesiologist guild's "restriction" of propofol use in some states (via nurse practice acts) and facilities (via credentialing) to anesthesia providers.

Until now, the objections to nonanesthesia propofol use I see cited here have been largely experiential or spiritual in nature (I believe this, my teacher told me, I saw this once in the GI lab...), and those professing these beliefs always completely dismiss substantial data showing that this drug is being used safely and effectively by nonanesthesiologists and their RNs (when both the physician and nurse are trained to do so, for moderate-deep procedural sedation) all over the world.

Fabulous! Now, you can additionally point to an unfortunate public event involving the clear misuse-abuse of this drug as further "evidence" supporting your guild's protective turf war. Incredibly relevant!

Can you tell us how you use propofol when performing endoscopy?

 

[DreamMachine]

Interesting posts...
It seems that there must be an incredible dearth of scientific data on your side supporting the anesthesiologist guild's "restriction" of propofol use in some states (via nurse practice acts) and facilities (via credentialing) to anesthesia providers.

I don't think a randomized controlled trial would get IRB approval because a bunch of people would die like Michael Jackson.

If you are so familiar with the drug, answer the question I asked you.

 

[dhb]

for moderate-deep procedural sedation

Getting a black snake shoved up your ***** without flinching is what we call GA

 

[Planktonmd]

Getting a black snake shoved up your ***** without flinching is what we call GA

It's really sad what people would do for money!
Now we have a GI attending defending a clueless EM resident just because he sees a political benefit in doing so.
It's all about money ladies and gentlemen.

 

[mountaingastro]

It's really sad what people would do for money!
Now we have a GI attending defending a clueless EM resident just because he sees a political benefit in doing so.
It's all about money ladies and gentlemen.

Wow! Amazing! Health care delivery and the allocation of scarce and valuable resources has a financial component? And I just wanted to learn about Jacko's propofol habit...

Let's do some "comparative effectiveness" research, because that is all the rage with the government types right now. For routine endoscopic sedation, what do you think the cost of substituting an anesthesiologist for endoscopist directed propofol sedation might be? The published figure is 5.3 million dollars per life year saved.

It will be interesting to see health care economists who argue about the cost effectiveness of interventions in the range of $50,000-$100,000 per life year chew on that!

With respect to professional compensation and my ability to profit from propofol administration, I am not paid a dime for my direction of sedation for an endoscopy. My fee, allowed amount and contracted amounts are the same if I:
-direct propofol sedation
-direct benzodiazepine-opioid sedation
-have an anesthesiologist manage sedation

With respect to facility compensation, as an owner, I would be able to remove an RN (and his or her salary) from my procedure room if an anesthesiologist or CRNA was providing sedation. I could even, if I felt so inclined, hire the anesthesiologist (i.e. profit off the anesthesiologist) if I wanted to employ the "company model" that is currently under fire from the ASA.

I can only profit from propofol if I have an anesthesiologist give it!

So, your suggestion that I am somehow benefiting financially by my position and the manner of my practice is folly.

Don't misinterpret my view here. I highly value the skills of my anesthesia colleagues and I readily use them for those cases in which I determine that the patient is high risk from the standpoint of their sedation, need a potentially long or complex therapeutic procedure (ERCP), or is at high risk of aspiration (esophageal food impaction, high grade upper GI bleeding, achalasia). My anesthesiologists have other and more appropriate clinical demands on their time and skill sets however that supercede them hanging out in the colonoscopy lab talking with me all day long.

How do I use propofol? Safely, and with due care.

Most of the procedures for which I direct sedation are EGDs and colonoscopies that I perform in a freestanding ASC (with no on site anesthesiologists), though I also do this on hospital outpatients and inpatients (unless I decide to ask for anesthesia consultation).

I perform a presedation airway and general physical assessment on all patients. Most patients receive a low presedation dose of midazolam (typically 1 mg). I usually do not use opioids or other adjunctive agents. We dose propofol by bolus, typically at 1 minute intervals, titrating to effect, targeting moderate-deep sedation. All patients receive oxygen by nasal cannula or mask, and all are capnographically monitored (along with oximetry, ECG and BP).

For a typical colonoscopy I will pass the instrument after 2 initial and usually decreasing doses that will range from 10-40 mg depending on age, size, physical status, and response 1 minute after the first dose). It is common for me to give 10 mg every minute to an average patient during left colonic intubation and 5 mg every minute once the proximal colon is reached. Propofol is discontinued during withdrawal through the transverse colon unless I plan to band hemorrhoids or do some other intervention late in the course of the exam. My median propofol dose, for colonoscopy after 1 mg midazolam presedation, is 135 mg (IQR 65 mg).

 

[DreamMachine]

Okay. I think you will rarely have problems with what you describe, because the doses of propofol are so small.

Who is giving the propofol and watching the patient while you are doing the colonoscopy?

 

[mountaingastro]

An RN who has no other duties administers sedation and monitors the patient. He or she converses with me prior to each dose regarding how much the next dose should be, or if it should be held.

Over the last 3 years I have directed sedation in over 3400 cases. I have mask ventilated 2 patients, for 1-2 minutes in each case, following which the procedure was continued to completion and additional propofol administered. In both cases the patient had been turned supine and airway obstruction ensued. We now avoid the supine position. If we must turn the patient supine, the depth of sedation is lightened enough to allow the patient to turn on their own, another RN is brought bedside for assistance and the bag-mask device is removed from the wall so that it is handy and we are thinking about it. My motto is bag early - bag often.

Over the last 2 years however, none of my own sedation patients have needed to be masked. I have masked one ERCP being sedated (natural airway) by an anesthesiologist who bolted from my room to attend a code on his prior patient in the recovery room (weekend with nobody around). I also assisted one of my pulmonology colleagues who was doing a bronch and whose patient was having some difficulty when I happened to be in the next room doing paperwork waiting for the bronchoscopy to finish.

 

[DreamMachine]

I think it's fine that you give propofol. Obviously, you know your limitations and are being vigilant. Unfortunately, I just don't believe most GI doctors are like this.

 

[Planktonmd]

The bottom line:I think you are full of crap and you won't know the difference between your ass and a Propofol pump even if it hit you in the face.

Wow! Amazing! Health care delivery and the allocation of scarce and valuable resources has a financial component? And I just wanted to learn about Jacko's propofol habit...

Let's do some "comparative effectiveness" research, because that is all the rage with the government types right now. For routine endoscopic sedation, what do you think the cost of substituting an anesthesiologist for endoscopist directed propofol sedation might be? The published figure is 5.3 million dollars per life year saved.

It will be interesting to see health care economists who argue about the cost effectiveness of interventions in the range of $50,000-$100,000 per life year chew on that!

With respect to professional compensation and my ability to profit from propofol administration, I am not paid a dime for my direction of sedation for an endoscopy. My fee, allowed amount and contracted amounts are the same if I:
-direct propofol sedation
-direct benzodiazepine-opioid sedation
-have an anesthesiologist manage sedation

With respect to facility compensation, as an owner, I would be able to remove an RN (and his or her salary) from my procedure room if an anesthesiologist or CRNA was providing sedation. I could even, if I felt so inclined, hire the anesthesiologist (i.e. profit off the anesthesiologist) if I wanted to employ the "company model" that is currently under fire from the ASA.

I can only profit from propofol if I have an anesthesiologist give it!

So, your suggestion that I am somehow benefiting financially by my position and the manner of my practice is folly.

Don't misinterpret my view here. I highly value the skills of my anesthesia colleagues and I readily use them for those cases in which I determine that the patient is high risk from the standpoint of their sedation, need a potentially long or complex therapeutic procedure (ERCP), or is at high risk of aspiration (esophageal food impaction, high grade upper GI bleeding, achalasia). My anesthesiologists have other and more appropriate clinical demands on their time and skill sets however that supercede them hanging out in the colonoscopy lab talking with me all day long.

How do I use propofol? Safely, and with due care.

Most of the procedures for which I direct sedation are EGDs and colonoscopies that I perform in a freestanding ASC (with no on site anesthesiologists), though I also do this on hospital outpatients and inpatients (unless I decide to ask for anesthesia consultation).

I perform a presedation airway and general physical assessment on all patients. Most patients receive a low presedation dose of midazolam (typically 1 mg). I usually do not use opioids or other adjunctive agents. We dose propofol by bolus, typically at 1 minute intervals, titrating to effect, targeting moderate-deep sedation. All patients receive oxygen by nasal cannula or mask, and all are capnographically monitored (along with oximetry, ECG and BP).

For a typical colonoscopy I will pass the instrument after 2 initial and usually decreasing doses that will range from 10-40 mg depending on age, size, physical status, and response 1 minute after the first dose). It is common for me to give 10 mg every minute to an average patient during left colonic intubation and 5 mg every minute once the proximal colon is reached. Propofol is discontinued during withdrawal through the transverse colon unless I plan to band hemorrhoids or do some other intervention late in the course of the exam. My median propofol dose, for colonoscopy after 1 mg midazolam presedation, is 135 mg (IQR 65 mg).

 

[mountaingastro]

The bottom line:I think you are full of crap and you won't know the difference between your ass and a Propofol pump even if it hit you in the face.

...and that from a moderator emeritus...

I am not full of crap, though I am board certified in the formative organ system.

Propofol pump...don't use 'em...maybe they do look like my rear.

This is a good discussion and I am long out of training but would have liked to have had the opportunity to share thoughts with those out in the clinical world when I was in my academic years.

The issue of sedation, and who should supervise it will not go away because of Jacko.

I agree that gastroenterologists unwilling to put the time and effort into their sedation practices should transfer that duty to one of you. I am a little nervous though over the trend to just hire a bunch of CRNAs and not have the knowledge to properly monitor and supervise what they do. After all, the propofol story that the public also knows about derived from unsafe injection practices in Las Vegas by CRNAs (and one anesthesiologist) which resulted in noscomial hepatitis C transmission and the largest public health notification of potentially affected patients in history.

 

[Planktonmd]

I am not sure I see the point of all that crap you just stated.

...and that from a moderator emeritus...

I am not full of crap, though I am board certified in the formative organ system.

Propofol pump...don't use 'em...maybe they do look my rear.

This is a good discussion and I am long out of training but would have liked to have had the opportunity to share thoughts with those out in the clinical world when I was in my academic years.

The issue of sedation, and who should supervise it will not go away because of Jacko.

I agree that gastroenterologists unwilling to put the time and effort into their sedation practices should transfer that duty to one of you. I am a little nervous though over the trend to just hire a bunch of CRNAs and not have the knowledge to properly monitor and supervise what they do. After all, the propofol story that the public also knows about derived from unsafe injection practices in Las Vegas by CRNAs (and one anesthesiologist) which resulted in noscomial hepatitis C transmission and the largest public health notification of potentially affected patients in history.

 

[mountaingastro]

I am not sure I see the point of all that crap you just stated.

The point is that I enjoy a spirited discussion, believe that anesthesia residents can learn something from their GI colleagues, and we from them, and I accept your insults. Thank you.

 

[Planktonmd]

The point is that I enjoy a spirited discussion, believe that anesthesia residents can learn something from their GI colleagues, and we from them, and I accept your insults. Thank you.

Great, So why don't you tell us something about something you know?
How about Achalasia and it's anesthetic implications?

 

[mountaingastro]

Plankto knows this, but for the sake of those who have not seen a de novo case of achalasia (1/100,000 population per year) the untreated patient with achalasia may have a liter or more of secretions and food from a few days ago in their esophagus, even if NPO for 12h or longer. These patients, in my practice, are intubated (by anesthesia) for airway protection prior to endoscopy. Once treated (botulinum toxin, pneumatic dilation, Heller myotomy) there should be sufficient clearance of the esophagus to allow for endoscopy under natural airway sedation, in most cases. Still, I keep them on clear liquids for the day prior to exam and strict NPO after midnight. If I enter a fluid filled esophagus and cannot immediately evacuate it with suction, the procedure is terminated and rescheduled, with anesthesia.

 

[Consigliere]

Plankto knows this, but for the sake of those who have not seen a de novo case of achalasia (1/100,000 population per year) the untreated patient with achalasia may have a liter or more of secretions and food from a few days ago in their esophagus, even if NPO for 12h or longer. These patients, in my practice, are intubated (by anesthesia) for airway protection prior to endoscopy. Once treated (botulinum toxin, pneumatic dilation, Heller myotomy) there should be sufficient clearance of the esophagus to allow for endoscopy under natural airway sedation, in most cases. Still, I keep them on clear liquids for the day prior to exam and strict NPO after midnight. If I enter a fluid filled esophagus and cannot immediately evacuate it with suction, the procedure is terminated and rescheduled, with anesthesia.

Schooled!

 

[Bertelman]

I like this guy.

 

[TenaciousGirl]

Plankto knows this, but for the sake of those who have not seen a de novo case of achalasia (1/100,000 population per year) the untreated patient with achalasia may have a liter or more of secretions and food from a few days ago in their esophagus, even if NPO for 12h or longer. These patients, in my practice, are intubated (by anesthesia) for airway protection prior to endoscopy. Once treated (botulinum toxin, pneumatic dilation, Heller myotomy) there should be sufficient clearance of the esophagus to allow for endoscopy under natural airway sedation, in most cases. Still, I keep them on clear liquids for the day prior to exam and strict NPO after midnight. If I enter a fluid filled esophagus and cannot immediately evacuate it with suction, the procedure is terminated and rescheduled, with anesthesia.

Served. 👍

 

[Planktonmd]

Plankto knows this, but for the sake of those who have not seen a de novo case of achalasia (1/100,000 population per year) the untreated patient with achalasia may have a liter or more of secretions and food from a few days ago in their esophagus, even if NPO for 12h or longer. These patients, in my practice, are intubated (by anesthesia) for airway protection prior to endoscopy. Once treated (botulinum toxin, pneumatic dilation, Heller myotomy) there should be sufficient clearance of the esophagus to allow for endoscopy under natural airway sedation, in most cases. Still, I keep them on clear liquids for the day prior to exam and strict NPO after midnight. If I enter a fluid filled esophagus and cannot immediately evacuate it with suction, the procedure is terminated and rescheduled, with anesthesia.