So I've never used Propofol before...

[EMperson]

---

Members don't see this ad.

So in residency we were only allowed to use Fentanyl and Versed for conscious sedation. This puts me only twenty years behind the rest of the EM world. At my new place, though, we're allowed to use Propofol. How do you guys do it?
Do you do the 1mg/kg loading followed by 0.5mg/kg boluses q3 minutes?
I've also heard of people giving a 20mg bolus and then when the patient is drowsy giving 10mg boluses prn. A friend of mine in anesthesia seems to do it in the most intuitive way by spiking the Propofol bottle, running it through micro drip tubing until the patient is out, then dialing it back just until the patient is about to wake up. After the procedure, he just shuts off the drip and the patient wakes up in 5 seconds.
Also, how do you manage co-administration of ketamine or fentanyl? About how much do you dial back the Propofol?

Thanks

 

[a_ditchdoc]

Usually I start with 60-80 mg for the average adult and then give 20 mg boluses every minute or two until adequate sedation, more for bigger guys and less for women and elderly. I'll call their name for a while to check sedation level. They'll give a groggy "Huhh?" for a dose or two, when they don't respond I'll tug on the injured part a little. If they wake right up I'll give a little more. I give the fentanyl just before the propofol if I use it. Patients don't have to be snoring. Almost everyone that has protested a little during a reduction has not remembered. Following the procedure they usually return to baseline in ten minutes or so. I really love the stuff. Just remember not to say something like "It's pretty safe, we use it all the time. It's the stuff Michael Jackson used."

 

[NateintheED]

I pretty much agree with what ditchdoc said. Everywhere I've worked, we've been allowed to use it, but the nurses can't push it. I'll usually push about 1mg/kg SLOW (if you push to fast, you're more likely to get apnea) and watch as they drift off. Some will go out before I get to that point, and that's when I stop.

As far as co-administration of other agents, with fentanyl, I'll give a pretty good dose (usually about 100mcg) a few minutes before I give the propofol.

With Ketamine, I use the protocol described in the Annals article from 2006:

A Prospective Evaluation of “Ketofol” (Ketamine/Propofol Combination) for Procedural Sedation and Analgesia in the Emergency Department , 27 October 2006
Elaine Victoria Willman, Gary Andolfatto
Annals of Emergency Medicine
January 2007 (Vol. 49, Issue 1, Pages 23-30)

Basically, make a 1:1 mixture of 10mg/ml ketamine & 10mg/ml propofol (giving you 5mg/ml of each drug). Then give a first dose of 0.5mg/kg of each drug, then redosing with 1-3ml of the mixture (5-15mg propofol/ketamine) when the patient starts to get light. I've never had this NOT work.

 

[kungfufishing]

It is easy to overshoot with propofol - it is fast but not instant, so give it a minute before you decide they need more.

With ketafol, you might try giving a 0.25-0.5 mg/kg slug of ketamine first, give it a few minutes to start doing the job, and then titrate your propofol on top of that. I've found this helps keep your ketamine from outliving your propofol, gives you all the analgesic benefit and anecdotally makes the reemergence less of an issue.

 

[GeneralVeers]

My favorite is Etomidate. Quick, short-acting, and predictable. Rarely do I have to give repeat doses.

 

[kungfufishing]

what brand of propofol is that?

 

[WilcoWorld]

I've become a big fan of "ketofol" which usually ends up being very close to 0.5 mg/kg of both propofol and ketamine. Ease 'em down with a slow propofol push, give the 0.5 mg/kg of ketamine once they're sleepy, give more propofol prn through the procedure (in 1cc or smaller aliquots) and they are usually waking up very soon after we're done. I've never had a puker, needed to manage an airway beyond a little jaw-thrust, or dropped a blood pressure with this regimen.

One drawback - This approach works best if you have a doc for the sedation and another for the procedure. Technically, that's how it's supposed to be done anyway, but I know we don't all follow every rule always.

 

[Apollyon]

The anesthesia guys give good reasons why they use propofol more than etomidate. EM folks counter back that etomidate is good.

JetPropPilot would state that "I could teach my mother how to give propofol", and I agree with him. I tell the patients, invariably, that they will come out of it and ask me when we are starting, and the procedure will be done, and, invariably, that is what occurs.

 

[DrQuinn]

I used to be an Etomidate kind of guy in residency but having been out 3 years now almost exclusively do propofol.

start ~ 60mg of propofol, then 20 mg aliquots until sedation achieved.

This is of course an average weight adult.
Q