propofol shortage. what to use for sedation after intubation?

[Painter1]

in residency i primarily used propofol as a drip for sedation for intubated patients.

turns out our hospital has a shortage. what other methods are you guys using for sedation. ativan drip? fentanyl drip? what rate?

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[Kubed]

The Cadillac of vent sedation right now is Precedex (1mcg/kg x1, then run at 0.2-0.7 mcg/kg/h. I've used it mostly for weaning (it's only approved for 24 hours of use at a time), but you could start someone on it and let the ICU change it later. Problem would be getting it up to the patient quick enough, a lot of people haven't used it, plus it's mucho $$$$$

When looking at sedation, most of what I've read seems to promote versed gtt over fentenyl gtt, but I think the reality is you go with whatever you can most easily get in the ED (as these seem to always need to be sent up from the pharmacy), and then PRN the other. For versed I start high and quickly back down (0.02-0.1 mg/kg/h) and PRN fentenyl 50 mcg q1. For fentenyl I start off at 100 mcg/hr and then PRN versed.

I'm interested to hear what others are doing (... apart from sending someone to break into the anesthesia supply room )

 

[docB]

Anoxia

 

[SoCuteMD]

Fentanyl/Versed. Like Fentanyl with Versed boluses.

Also, brutane.

 

[xaelia]

Barring contraindications, I think we were pretty much a fentanyl/ativan gtt shop.

Now the movement in our MICU here is fentanyl gtt, ativan PRN, with gtt when the vent settings are crazy or some other reason they need to be fully sedated.

I'd stay away from versed gtt because the volume of distribution gets you in trouble if you're on it too long, as your wean could take days.

Just make sure you're providing adequate analgesia along with your sedation, whatever you use.

And no neuromuscular depolarizing agents for agitation.

 

[Interpolfanclub]

This thread shows the variety in sedation. Seems like just about everyone was using propofol. Now that it isn't so available I generally default to versed gtt with some fentanyl. I've also used ativan and fentanyl both separately in peds patients.

 

[Painter1]

so when i review the drip ranges they are pretty wide. in an emergent situation i like to keep things simple. is the below reasonable for your average human s/p intubation who begins to thrash around:

if using versed, 5mg versed IVP then 5mg/hr drip?

if using fentanyl, 100mcg IVP, then 50mcg/hr drip?

if using ativan, 3mg IVP, then 3mg/hr drip?

if using propfol, 30mg IVP, then 20mcg/kg/min titrate up to 50mcg/kg/min?

if using morphine, 4mg IVP, then 4mg/hr drip?

anyone care to make changes, give their input.

in my case, i intubated an OD then ordered propofol, to my surprise there was none in the ED. i realized that as a resident i should've switched it around to get experience with other methods of sedation. not fun when i have to dance around and read through my pharmacopia as the nurses look at me desparetly waiting for an order!

 

[njac]

where I am now is all about the fentanyl and versed gtt's.

 

[deleted109597]

Recent critical care literature has implied that prolonged benzo use might cause, for lack of a better word, dumbing. Apparently it makes them not as bright as they were prior to the prolonged ventilation.
Some of the newer guys here really like precedex, but as mentioned before, it isn't cheap. It also doesn't really put people down like versed.

 

[diphenyl]

Can't go wrong w/ fent and versed. I used to hate propofol drips. Its half life is so short its not uncommon for pts top wake up while the nurse is changing drips, so in the MICU they usually have boluses standing by just in case while they change them.

 

[njac]

and not everyone has Precedex openly available. I am at a smaller teaching hospital and we have it on (ridiculous, IMO) lockdown. Only attendings can write for it, 24 hour absolute max, etc etc.

 

[gutonc]

Not to get completely OT, but this begs the question (that I've had with lots of other drug shortages). What was AstraZeneca thinking? How did we get to a shortage of propofol in the first place? Michael Jackson is dead so it must be at least semi-legit uses responsible for the consumption of it. I assume all of this is tracked. Did they not at least send somebody to the warehouse to look and see how much was left?

Ummm...fentanyl and versed.

 

[njac]

Not to get completely OT, but this begs the question (that I've had with lots of other drug shortages). What was AstraZeneca thinking? How did we get to a shortage of propofol in the first place? Michael Jackson is dead so it must be at least semi-legit uses responsible for the consumption of it. I assume all of this is tracked. Did they not at least send somebody to the warehouse to look and see how much was left?

Ummm...fentanyl and versed.

I believe there were issues with generic propofol a couple months ago. So they had to pull those batches out of circulation and we ended up with the current situation. I know for awhile we were getting Propoven, which is the European version.

 

[WilcoWorld]

so when i review the drip ranges they are pretty wide. in an emergent situation i like to keep things simple. is the below reasonable for your average human s/p intubation who begins to thrash around:

if using versed, 5mg versed IVP then 5mg/hr drip?

if using fentanyl, 100mcg IVP, then 50mcg/hr drip?

if using ativan, 3mg IVP, then 3mg/hr drip?

if using propfol, 30mg IVP, then 20mcg/kg/min titrate up to 50mcg/kg/min?

if using morphine, 4mg IVP, then 4mg/hr drip?

anyone care to make changes, give their input.

in my case, i intubated an OD then ordered propofol, to my surprise there was none in the ED. i realized that as a resident i should've switched it around to get experience with other methods of sedation. not fun when i have to dance around and read through my pharmacopia as the nurses look at me desparetly waiting for an order!

Given that I treat acute pain with 0.1mg/kg to start, that morphine dose seems a little low to me for vent sedation on the average adult.

 

[kungfufishing]

I think your doses are a little low, but maybe I'm overdosing everybody. I find that I end up using double many of those doses if not more. For example, 150 mics of fentanyl over an hour just isnt that much fentanyl for an average adult.

 

[deleted109597]

Plus some people require more sedation than others, even at the same weight.
I've had completely awake people not requiring sedation, and other people on concentrated dilaudid drips.
Titrate to effect usually works the best for me. And if they're on the vent, no worries about losing the airway (just the BP).

 

[ER-ER-Oh]

I use Versed and Fentanyl, start the Versed at 2mg gtt and titrate up. We fly patients on this from our rural ED to the main center, and I use it at the main until they get to the Unit, then they can do whatever they need to keep them from getting dumb.