Propofol.. white lightning

[Joshua Benton]

Hello everyone,..

I have been reading some of the postings and wow!! you guys are really talking about some great stuff. I am posting under a new ghost name. I used to post under the name Whelson P. Monroe and was responsible for getting the Scenario section to be a regular topic of discussion. I remember some you like RID and ACE and we had great discussions and learned plenty. But enough of reminiscing and on to the topic. I recently transported an active IC Bleed from a small local ICU to a Level I medical center. She intubated and was being sedated with Propofol and I was wondering how many of you routinely transport patients on this med and what you think about its efficacy, SE, precautions etc. and you experiences with it. The trip was 2 and 1/2 hours and she needed to be snowed for the trip. I would greatly appreciate any anticdotal info you might have and if you use it, what your protocol is for admin.

thank you all in advance... I really missed this place

Much love and Respect

Joshua

[chbare]

Joshua Benton, we use it quite a bit on sedated and intubated patients in our ICU. I have had good experiences with propofol and it is fast acting and quick to wear off. The most common side effect that I have experienced is hypotension. Check out the following link to an entire thread on propofol.

http://www.emtcity.com/phpBB2/viewtopic.ph...opofol+seizures

If I remember, Spock posted some good stuff on propofol.

Take care,

chbare.

[flightmedic608]

Hello, we usually D/C the infusion for our transports. When we transport anyone who is intubated, we use IV boluses of Fentanyl/Lorazepam/Midazolam for analgesia/sedation. The are some risk vs benefits of using Propofol like anything else you need to weigh them. I personally like using IV boluses of medication, I have found the using Propofol in the transport environment tends to keep the patient too "light" and increase their PIPS. This is just one opinion, I am sure that there are many.

[Joshua Benton]

Thank you for directing me to that other thread. Lots of good stuff.....but I now have other questions... This patient with the active IC bleed was treated initally with Sodium Nitroprusside for her pressure.....( No A line, very large lady and no pressure cuff large enough to fit her. .. used ankle cuff and doppler to assess) and on O2 per NRB until just prior to transport by ground (no flight big enough to handle) then crumped and had to be intubated....started on propofol and then her pressure bottomed out...started her on Dopamine for pressure. We had to manually ventilate her with BVM for the 2!/2 trip (another story, another time)...we were balancing her LOC with her SBP and now I am wondering if her cerebral perfusion pressure was adequate for the trip... or could we have used a better combo than Dopamine and propofol......

Much love and Respect

Joshua

[FormerEMSLT297]

Interesting u mentioned propofol.... i would be interested to know if any agencies carry this medication for pre-hospital use. From what I understand the medication is not routinely carried because it requires great temperature control and constant refrigeration.

[chbare]

Joshua Benton, bad situation. I would be very careful about sedating head bleeds. You are correct to worry about blood pressure. The goal of our care is to prevent secondary insults, and hypoperfusion along with hypoxia are very common causes of secondary cell injury. Have you considered presenting this patient as a scenario or case study. The background, history, and complete assessment of this patient would give us more information to base our responses. Here is a good article of subarachnoid hemorrhage management. The pharmacology is also discussed in this article.

http://www.emedicine.com/EMERG/topic559.htm

Take care,

chbare.

[AZCEP]

I have to agree with chbare on this one. Propofol is very good for sedation, but using it on a known head bleed is asking for trouble. Fentanyl/Versed would be a more common mix in my area. Versed would be the occasional IV bolus, with Fentanyl by infusion.

[Joshua Benton]

Thanks chbare and azcep for your responses. I will gather my notes and jog my memory to present this as a scenario. It was, needless to say, a high pucker factor transport. I really feel that this type of critical care transfer will become common place for an ALS equipped truck not necessarily a critical care truck. I will present this in the scenario section and we can all learn.

Much Love and Respect

Josh B.

[flight-lp]

Interesting u mentioned propofol.... i would be interested to know if any agencies carry this medication for pre-hospital use. From what I understand the medication is not routinely carried because it requires great temperature control and constant refrigeration.

too expensive, too risky, not needed in the pre-hospital environment.......................

[Ace844]

I recently transported an active IC Bleed from a small local ICU to a Level I medical center. She intubated and was being sedated with Propofol and I was wondering how many of you routinely transport patients on this med and what you think about its efficacy, SE, precautions etc. and you experiences with it. The trip was 2 and 1/2 hours and she needed to be snowed for the trip. I would greatly appreciate any anticdotal info you might have and if you use it, what your protocol is for admin.

thank you all in advance... I really missed this place Thank you for directing me to that other thread. Lots of good stuff.....but I now have other questions... This patient with the active IC bleed was treated initally with Sodium Nitroprusside for her pressure.....( No A line, very large lady and no pressure cuff large enough to fit her. .. used ankle cuff and doppler to assess) and on O2 per NRB until just prior to transport by ground (no flight big enough to handle) then crumped and had to be intubated....started on propofol and then her pressure bottomed out...started her on Dopamine for pressure. We had to manually ventilate her with BVM for the 2!/2 trip (another story, another time)...we were balancing her LOC with her SBP and now I am wondering if her cerebral perfusion pressure was adequate for the trip... or could we have used a better combo than Dopamine and propofol......

Much love and Respect

Joshua

"WPM, Joshua Benton,"

[marq=left:0c4dc0bea0]WELCOME BACK BROTHER!!! WE'RE GLAD TO HAVE AN EXCELLENT RESOURCE RETURN AGAIN TO CONTRINBUTE HERE!!![/font:0c4dc0bea0][/marq:0c4dc0bea0]

Now with that out of the way here are some more links to info on propofol in this setting here.

http://www.ncbi.nlm.nih.gov/entrez/query.f...p;dopt=Abstract

http://jnnp.bmjjournals.com/cgi/content/full/73/1/94

http://www.diprivan.com/sedation/science.a...hownav=sedation

http://www.ncbi.nlm.nih.gov/entrez/query.f...p;dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/query.f...p;dopt=Abstract

http://www.blackwell-synergy.com/doi/full/...3.x?cookieSet=1

http://www.neurosurgery-online.com/pt/re/n...9856144!8091!-1

Propofol for Sedation in Critically-Ill Neurologic Patients

Principal Investigator: Dr. Gary L. Bernardini

Department of Neurology

Division of Critical Care Neurology

Co-Investigator: Dr. Stephan Mayer

Department of Neurology

Division of Critical Care Neurology

This a prospective, observational study whose primary goal is to to evaluate the use and effectiveness of propofol as a sedative agent in the setting of a Neuro-Intensive Care Unit (NICU).

Subjects will include patients 18 years of age and older who are on mechanical ventilation, have been admitted to the Neurologic Intensive Care Unit (NICU) for treatment of a significant neurologic condition (typically traumatic brain injury or stroke), and are receiving propofol as prescribed by their attending physician as part of their standard treatment regimen. During induction and discontinuation of propofol, sedation and agitation levels, and neurologic status of each subject will be evaluated and recorded using the modified Ramsey scale, a 6-point agitation scale (which assesses spontaneous motor activity and response to being on mechanical ventilation), and the Glasgow Coma Scale. respectively. In addition, heart rate, respiratory rate, blood pressure, mean arterial pressure, O2 saturation, propofol dosage, any side effects to the drug, and length of time on the drug will be recorded. Baseline vital signs, sedation and agitation levels, and neurologic status will be measured 10 minutes prior to induction and discontinuation of propofol.

(“Anesthesia For The Surgery Of Intracranial Aneurysms:

Part IV

Jose Luis Martinez-Chacó Crespo @ M.D

Médico Adjunto

Servicio de Anestesiologíy Reanimació

Hospital Universitario de la Princesa

Citation:

Jose Luis Martinez-Chacó Crespo: Anesthesia For The Surgery Of Intracranial Aneurysms: Part IV. The Internet Journal of Anesthesiology. 1998. Volume 2 Number 4. http://www.ispub.com/ostia/index.php?xmlFi...n4/aneurysm.xml ”)

Propofol produces a significant reduction of CBF, ICP and in a lesser degree of the CMRO2. However, its use as a cerebral protector is not recommended by several authors because its seizure-like activity after anesthesia. Propofol has a hemodynamic profile similar to the barbiturates and etomidate and like them it produces a suppression of the EEG. Animal studies have been confusing in demonstrating its cerebral protecting effects ( 156 , 157 ). More extensive studies are needed regarding propofol before it can be recommended as a cerebral protector.

Isoflurane has been proved to have inferior effects compared to barbiturates ( 158 ).

Anecdotally I have transported similar patients with the same C/C, and Rx but for shorter periods of anywhere from 10-50 mins., long on avg. and have seen little deleterious effects. U sually we see hypotension with this med and it spontaneously resolves when you 'back-down' or alter the sedation drip.

Hope this helps,

ACE844