phenylephrine and propofol

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epidural man

epidural man

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Hey all -

Happy Holidays!

I have been mixing my propofol with phenylephrine (about 200- 300mcg in a 200mg) in patients that I don't want their blood pressure to dip much on induction. I started doing it because I couldn't think of a good reason NOT to do it. I hate etomidate so I never use that. Ketamine isn't always appropriate and I don't like using induction doses anyway (the max i ever use is 0.5mg/kg on induction). So the mix is what I came up with.

I haven't seen much written on it (although I admit I haven't looked with much vigor).

Any thoughts?

Bad idea? Good idea? Stupid idea? Crazy idea? I should stop thinking?
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I tried that as a resident but stopped because it just didn't make any sense to me. There isn't much out there in the literature so don't bother.

What IS out there is that the elderly, sickies and trauma patients need a small fraction of the induction dose you would give a healthy person. I make sure the pt is euvolemic, titrate in fentanyl and find I use around half the induction dose with minimal hypotension and zero recall.

I like control and titration, combining induction drugs in one syringe is lazy and removes that control...its a crna move.
 
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desflurane said:
I tried that as a resident but stopped because it just didn't make any sense to me. There isn't much out there in the literature so don't bother.

What IS out there is that the elderly, sickies and trauma patients need a small fraction of the induction dose you would give a healthy person. I make sure the pt is euvolemic, titrate in fentanyl and find I use around half the induction dose with minimal hypotension and zero recall.

I like control and titration, combining induction drugs in one syringe is lazy and removes that control...its a crna move.
Click to expand...

No it's not. And what does that mean any way?

Just because you mix drugs doesn't imply you don't titrate. And just because you mix them, doesn't mean you give the whole thing. I never even came CLOSE to implying that. Regardless, some people, if you give 40 mg propofol on induction, they still get very hypotensive. I have found mixing some neo helps.

Give me a downside to mixing it. Does it prevent you from giving more of neo from it's own syringe? No. That's a ******ed idea. Could it make them hypertensive? Unlikely - but even so, people tolerate hypertension much better than they do hypotension.
 
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I'm not a mixer, though I certainly 'pre-treat' expected induction hypotension with phenylephrine or ephedrine before it comes up on the monitor.

I used to mix neostigmine and glycopyrrolate in the same syringe, but not any more.

I had an attending who used to make me mix propofol, Versed, ketamine, and sufentanil all in one big syringe for TIVA cases. I hated it.


I guess the only thing I routinely mix in one syringe now is ketafol.
 
My point is I don't like to guess at what I'm giving on induction. I've never seen anything (haven't really looked) showing that phenylephrine diluted with NS and Propofol becomes uniformly distributed in the syringe and is therefore a known quantity when its injected. I don't like injecting unknown quantities into patients. Anal? Yes I'm super anal.

I also prefer more flexibility on the fly than less. What happens after you inject your concoction, attempt laryngoscopy and the HR goes to 28? Was it your Neo or your laryngoscopy? Does it matter? I think it does.

I suppose the crna comment was harsh but I've had to squash many a "shortcut" from both residents and nurses. The nurses are usually the ones that continue to do what they want.
 
had a cardiac attending who would mix fentanyl, etomidate, pancuronium, and phenylephrine in a 60cc syringe for every case, and push the whole thing with the cefazolin. rock solid stable every time.

personally i like to titrate. i don't mix em. it's easy to just push a little propofol, then a little phenylephrine.

i try to limit most pts to one vial of propofol/case - if you mix it with phenylephrine you can't use a smidge later without giving neo...
 
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desflurane said:
My point is I don't like to guess at what I'm giving on induction. I've never seen anything (haven't really looked) showing that phenylephrine diluted with NS and Propofol becomes uniformly distributed in the syringe and is therefore a known quantity when its injected. I don't like injecting unknown quantities into patients. Anal? Yes I'm super anal.

I also prefer more flexibility on the fly than less. What happens after you inject your concoction, attempt laryngoscopy and the HR goes to 28? Was it your Neo or your laryngoscopy? Does it matter? I think it does.

I suppose the crna comment was harsh but I've had to squash many a "shortcut" from both residents and nurses. The nurses are usually the ones that continue to do what they want.
Click to expand...

:thumbup::thumbup:
 
Background The induction of general anaesthesia is associated with the greatest cardiovascular changes in elderly patients. Induction can be performed either intravenously or with gaseous induction. Sevoflurane has advantages over propofol for induction of anaesthesia in the elderly, since the lower reduction in mean arterial pressure with sevoflurane is both statistically and clinically significant. This prospective randomized controlled trial investigated the cardiovascular benefits of co-induction of anaesthesia with 0.75 mg kg−1 propofol and 8% sevoflurane, when compared with 8% sevoflurane alone in patients requiring surgery for fractured neck of femur.
Method In total, 38 patients aged 75 or over were allocated into the two groups, receiving either 0.75 mg kg−1 of propofol followed by 8% sevoflurane or 8% sevoflurane alone. Vital signs were recorded until successful insertion of a laryngeal mask. Induction times, induction events and patient satisfaction scores were also recorded.
Results Results showed that there were no differences in the cardiovascular parameters between the two groups. Induction times were faster in the propofol and sevoflurane group (62 vs. 81 s; P = 0.028). The postoperative questionnaire showed that the majority of patients in both groups were satisfied with the induction process.
Conclusions We concluded that 0.75 mg kg−1 of propofol followed by sevoflurane induction is an acceptable alternative to sevoflurane induction. It is associated with similar haemodynamic variables, faster induction times and is very well tolerated.


http://www.ncbi.nlm.nih.gov/pubmed/17888191
 
I mix a lot of agents... Prop, roc, decadron for example. I don't mix pressors however.
 
Like blade is describing, I use markedly low doses of propofol + fent/precedex + sevo... Although I don't find 8% necessary.... more like 2-3%. Laryngophed keeps the BP pretty close to nml.

Always have 50-150mg of prop left over for the rest of the case.
 
I figure the more syringes I use, the more complicated my job appears. If I do everything in one syringe, people will think a robot could do my job.

Plus, it makes labeling that much more difficult.
 
Lidocaine (150 mg iv)
Fentanyl 5cc (50 mcg) for adults or 3 cc for geriatrics
Propofol: for age>40, double age and minus it from 200. Thats the induction dose.
Sux: 100 mg
Ventilate once or twice while waiting for 30 seconds.
Intubate

I almost never reach for phenylephrine.
 
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RxBoy said:
Lidocaine (150 mg iv)
Fentanyl 5cc (50 mcg) for adults or 3 cc for geriatrics
Propofol: for age>40, double age and minus it from 200. Thats the induction dose.
Sux: 100 mg
Ventilate once or twice while waiting for 30 seconds.
Intubate

I almost never reach for phenylephrine.
Click to expand...

:confused:
your fent is 10mcg/cc?
prop dose for asa 1 50 y/o is 100mg?
sux for everyone?

:eek:
 
dhb said:
:confused:
your fent is 10mcg/cc?
prop dose for asa 1 50 y/o is 100mg?
sux for everyone?

:eek:
Click to expand...

Using this regimen, you have to give sux to everyone so they don't reach up to grab the laryngoscope out of your hand.
 
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RxBoy said:
Lidocaine (150 mg iv)
Fentanyl 5cc (50 mcg) for adults or 3 cc for geriatrics
Propofol: for age>40, double age and minus it from 200. Thats the induction dose.
Sux: 100 mg
Ventilate once or twice while waiting for 30 seconds.
Intubate

I almost never reach for phenylephrine.
Click to expand...


Do you really use this cocktail on everyone?
 
My concern with the Propofol and Phenyl concoction would be the HR. Propofol does have a myocardial depressant effect. Additionally, Pheylephrine can cause reflexive Brady.

I think the two 'mixed' could precipitate severe brady cardia. Additionally, how could you determine which is the drug that caused the brady?

On the flip side , the treatment of the brady would be the same I suppose....
 
PinchandBurn said:
My concern with the Propofol and Phenyl concoction would be the HR. Propofol does have a myocardial depressant effect. Additionally, Pheylephrine can cause reflexive Brady.

I think the two 'mixed' could precipitate severe brady cardia. Additionally, how could you determine which is the drug that caused the brady?

On the flip side , the treatment of the brady would be the same I suppose....
Click to expand...

Med student "mental masturbation" ahead: propofols cardiac depressant effect is an agent specific effect if I understand correctly whereas phenylephrines reflex Brady is secondary to an acute rise in BP as felt by the carotid sinus..... So if the phenyl added to the prop was effective in negating any change in BP you shouldn't see Brady due to the phenyl. This assumes the pre-added dose of phenyl was the exact dose needed however.
 
Propofol by itself often gives you an increase in HR (due to pain or decrease SVR with reflex increase in HR/tachy in an attempt to maintain CO).

Neo nearly always slows down the HR.

If I was to mix them and get brady, I would assume the decrease in HR is due to neo. In the right patient, it may be due to both.
 
If you put 200-300mcg of phenylephrine in to 200mg of propofol, then induce a 90yo for a femur fracture, I assume you'd give ~100mg of propofol at most, and so then this would be 100-150mcg of phenylephrine, which is probably what you would give if you had them in separate syringes. These elderly sick patients typically need repeated boluses of phenylephrine because the phenylephrine wears off pretty quick and they don't seem to bounce back from the propofol that fast -- I don't see anything wrong with mixing phenylephrine in as long as you 1) still reduce your total propofol dose and 2) have a stick of phenylephrine or ephedrine ready. And since you still need to have a stick of Neo around, it kinda defeats the point of mixing.
 
dhb said:
:confused:
your fent is 10mcg/cc?
prop dose for asa 1 50 y/o is 100mg?
sux for everyone?

:eek:
Click to expand...

Fentanyl 250 mcg (5 cc of 50 mcg/ml)
And yes would give 100 mg of propofol

Fentanyl blocks the sympathetics, Propofol gives the amnesia.
 
RxBoy said:
Fentanyl 250 mcg (5 cc of 50 mcg/ml)
And yes would give 100 mg of propofol

Fentanyl blocks the sympathetics, Propofol gives the amnesia.
Click to expand...

hope that's a long case or you will have the slowest wake up and room turnover time around. In quick PP land, adult patient rarely need more than 50 to 100 mcg fentanyl for the entire case unless it's > 60 minutes or exceedingly painful.

I have no recipe. I titrate each drug to the desired effect for that patient and that procedure. Some 50 year olds need 300 of propofol (170 kg gastric bypass patient), others need less than 100. The answer for everything is "it depends". Never get stuck trying to do the same thing for different patients just because you can usually get away with it.
 
Thanks for the discussion.

Thanks for the replies.

I don't think I have ever seen someone brady down to 28 from neo that was given for hypotension that needed treating. That seems unlikely to me.


I still like the idea of mixing the two. It makes me feel sexy and want to do the moon dance. Although i wish I could do the sponge bob. My 12 y/o does that so fast. I can't seem to get it...i'm getting older.....so sad.
 
Bertelman said:
I figure the more syringes I use, the more complicated my job appears. If I do everything in one syringe, people will think a robot could do my job.

Plus, it makes labeling that much more difficult.
Click to expand...

True, I love having 5 syringes next to the patients head, 2 in line on stop cocks, and at least 3 more in my pocket. OR staff is like whoa........this dude is serious.:D
 
More like 250-350 mg Propofol. Nothing premixed; titrated. may need neo, maybe not.

larygo-nephrine works too.
 
Per4mer8 said:
Med student "mental masturbation" ahead: propofols cardiac depressant effect is an agent specific effect if I understand correctly whereas phenylephrines reflex Brady is secondary to an acute rise in BP as felt by the carotid sinus..... So if the phenyl added to the prop was effective in negating any change in BP you shouldn't see Brady due to the phenyl. This assumes the pre-added dose of phenyl was the exact dose needed however.
Click to expand...

One thing about adding phenyephrine is that it is an alpha 1 agonist, but propofol cardiac effects are primarily through beta 1 effects. So essentially by giving phenyephrine you are treating a number. You actually don't increase your cardiac output or overall end organ perfusion, which is the overall point. Provided their heart rate is stabile, I like ephedrine first. If their heart is really stimulated from airway instrumentation, I like phenylephrine. But what I am trying to get at is I don't just like running for a "blood pressure medication" and mixing it up before I see what happens. Every team you push a drug, there needs to be a reason why. Pre-mixing seems to be a little too presumptuous.

What if you draw up 20cc, and push 15cc, then you plunk the first tube and the patient starts waking up? His HR and BP skyrocket from what you just did, but you need to put him back down? Do you push your propofol with the phenylephrine in it even though you have a BP of 170/80?

Anyhoo, it's convenient, but I like just giving the drugs separately.
 
I really do not like the idea of mixing pressors with any other medications, especially with vasodilators. It seems you could create more problems than solving it.
 
As if all those drugs are not mixed in the IV tubing or the bloodstream :D

Guys and gals, what is so bad with mixing the drugs which are chemically compatible ?

Don't usually mix propofol with phenylephrine, but if I have to, do not see any specific contraindication to it.
 
Ignatius J said:
One thing about adding phenyephrine is that it is an alpha 1 agonist, but propofol cardiac effects are primarily through beta 1 effects.
Click to expand...

Is that true?
 
pgg said:
I guess the only thing I routinely mix in one syringe now is ketafol.
Click to expand...

It wouldn't be ketafol otherwise; This is my routine as well.

sevoflurane said:
Always have 50-150mg of prop left over for the rest of the case.
Click to expand...

Same here. I know it drives my partners crazy, when they relieve me and have to record the waste in the pyxis at case end. The manufacturer's should just make it in 10ml vials for me.

----------
On topic, I don't fault the OP on his induction mix.

One particular attending I'd had liked putting a vial of phenylephrine into the pt's mainline IV bag if they were sorta "soft" - that drove me crazy; I'd rather bolus minute doses of pressor semi-continuously.

I'm also not a fan of the vial of phenylephrine in a 100ml/250ml bag on a micro-drip/roller clamp; Although I'm sure one day when I don't have time to program a pump, it'll come in handy to "buy time."
 
Ignatius J said:
I thought I had read that somewhere, so I was second-guessing myself with your question.

I looked up a quick article on it. It is a complex interaction, but yes, effects appear to be because of decreased inotropy. Here ya go:

http://www.anesthesia-analgesia.org/content/93/3/550.full
Click to expand...

It's widely known that propofol can act as a negative inotrope. Having said that, it also reduces SVR and I believe that this is (largely) the cause of hypotension associated with it's use.

In fact, the article you posted concludes:

"In summary, our study revealed that propofol produces a concentration-dependent decrease in myocardial contractility at supratherapeutic concentrations in vitro. However, in concentrations equivalent to those used clinically, this negative inotropic effect was not significant even in failing myocardium."
 
So, does propofol have any beta effects?
 
From Miller:
Table 26-2 Hemodynamic Changes after Induction of Anesthesia with Nonbarbiturate Hypnotics
Propofol
HR ± 10%
MBP −10-40%
SVR −15-25%
PAP 0-10%
PVR 0-10%
PAO Unchanged
RAP 0-10%
CI −10-30%
SV −10-25%
LVSWI −10-20%
dP/dt Decreased
Click to expand...

Also
Propofol at high concentrations (10 μg/mL) abolishes the inotropic effect of α but not β adrenoreceptor stimulation, and enhances the lusitropic (relaxation) effect of β stimulation."
Click to expand...
 
lushmd said:
It's widely known that propofol can act as a negative inotrope. Having said that, it also reduces SVR and I believe that this is (largely) the cause of hypotension associated with it's use.

In fact, the article you posted concludes:

"In summary, our study revealed that propofol produces a concentration-dependent decrease in myocardial contractility at supratherapeutic concentrations in vitro. However, in concentrations equivalent to those used clinically, this negative inotropic effect was not significant even in failing myocardium."
Click to expand...

Yep, I just got owned.

To the poster above, yes and no is the answer. It has negative inotropic effects had high plasma concentration levels. But yes, hypotension appear to be related moreso to a decrease in SVR.
 
Any induction agent or combination of agents can be dangerous if you don't know what you are doing.
For example combining 0.75 mg/kg of Propofol with 8% Sevo is almost guaranteed to cause extreme badness in the typical 90 Y/O dehydrated patient coming for an ORIF of a hip.
Every patient is different and every patient deserves a thoughtful plan by a consultant anesthesiologist.
Lets leave the cook book recipes to our nurse colleagues.
 
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