Propofol for RSI

[sluggs]

Dosing for propofol for RSI seems to be an issue creating confusion at my institution. My standard cocktail is: 50-150 mcg fent, 30-70 mg prop (if not too unstable) and then paralyze. Anybody use a different dose of propofol (I try to be about .4-.6 mg/kg)? I use ketamine or versed otherwise.
Thoughts?

 

[MTGas2B]

For the hemodynamically unstable adult patient needing RSI my rough dose of propofol is roughly systolic minus 50 plus relaxant (sux or roc). No narcs or benzos pre RSI.

Opinions may vary.

 

[Hernandez]

For the hemodynamically unstable adult patient needing RSI my rough dose of propofol is roughly systolic minus 50 plus relaxant (sux or roc). No narcs or benzos pre RSI.

Opinions may vary.

So you'd use as little as 10-20mg prop on top of a paralytic?

 

[MTGas2B]

If the pressure is in the toilet I will. Midaz can give retrograde amnesia once the airway is secured.

 

[proman]

If the pressure is in the toilet I will. Midaz can give retrograde amnesia once the airway is secured.

I don't think benzos give any retrograde amnesia. Usually critical illness gives great retrograde amnesia. So does hypoxia or hypercarbia.

 

[MTGas2B]

Usually critical illness gives great retrograde amnesia. So does hypoxia or hypercarbia.

In a true urgent/emergent intubation it doesn't take much hypnotic to get the job done

 

[pseudoknot]

1 mg/kg is normally what I use if they are stable.

If they are hemodynamically unstable then don't use propofol. Just don't.

 

[Bostonredsox]

1 mg/kg is normally what I use if they are stable.

If they are hemodynamically unstable then don't use propofol. Just don't.

/nod

If they are crashing but still have a gag and can fight I etom/succ as they are in the kit together. If they do not have either as the emergent airway is perhaps a code, I generally do not need any agents. If they are unstable and it is urgent but not emergent, meaning I have 5 minutes or so, I generally use 5 of versed and succ. I really do not like using propofol unless it is the normo-or-hypertensive COPDr that I am electively tubing because they are failing bipap.

 

[MTGas2B]

There are a lot of ways to skin this cat. Crashing/crumping patients can easily be hurt by textbook hypnotic doses. The goals are: hope they forget, optimize your intubating conditions, and do it an expedient manner. IMHO the first is the least important. I would rather apologize for a bad memory than thump on someone's chest.

 

[Hernandez]

I wasn't being critical, my only experience with a pt being tubed with paralytic alone a) didn't need to be intubated and b) was gagging horribly wih the first med-less look the look took and since then I've taken "there is a special place in hell for people who push paralytics without sedatives" but I shouldn't say never as peri-code conditions do change the situation

 

[proman]

I don't think benzos give any retrograde amnesia. Usually critical illness gives great retrograde amnesia. So does hypoxia or hypercarbia.

I completely agree. I just didn't want anyone to think that midazolam provides any retrograde amnesia.