Propofol for procedural sedation

[pinipig523]

I have some experience with proposal but I wanted to get a sense of what the other guys here use.

I usually just do slightly less than 1mg/kg initial bolus and then re-bolus as needed at a little less than 0.5mg/kg. So in an 80kg pt, I usually just do 60 + 30 + 30 as needed. I've only done this twice.

What about you guys?

I've heard that some just do like 40 + 20 + 20 + 20 until adequately sedated on a 80kg patient. While others just give a slug of 80 then re-bolus at 40 at a time on an 80kg patient.

How quickly do you guys redose? And how quickly do you guys wait for sedation to kick in?

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[tkim]

unless very old or young i give them a 1 mg/kg slug, then 'feather' light touches during the procedure.

 

[southerndoc]

I just keep pushing (at a fairly fast rate) until they're sedated. I don't calculate dosages as I've found that it causes a variable response.

 

[dotcb]

40 or 50 bolus + 20, 20, 20, etc. I have had a few apneic patients with propofol recently, all of which responded with chin lift and stimulation. Always have your back-ups equipment ready and I feel nasal ETCO2 is a valuable addition.

 

[pinipig523]

I just keep pushing (at a fairly fast rate) until they're sedated. I don't calculate dosages as I've found that it causes a variable response.

So how quickly do you push boluses and how long do you wait in between?

 

[EctopicFetus]

Weird case.. I was doing a procedure and a partner was sedating a pretty healthy 60 yr old. Long story short the guy becomes apneic but then we bag him and he just desats. Interestingly he wasnt fat etc. Nothing to make you think it would have been hard to bag. We were bagging wihtout much resistance but the guys sats dropped way down, then popped up to a still low number until he got tubed. I was wondering if the guy bronchospasmed or what. No ketamine.. just a straight propofol sedation. Wondering on thoughts from the others on here.

 

[pinipig523]

Weird case.. I was doing a procedure and a partner was sedating a pretty healthy 60 yr old. Long story short the guy becomes apneic but then we bag him and he just desats. Interestingly he wasnt fat etc. Nothing to make you think it would have been hard to bag. We were bagging wihtout much resistance but the guys sats dropped way down, then popped up to a still low number until he got tubed. I was wondering if the guy bronchospasmed or what. No ketamine.. just a straight propofol sedation. Wondering on thoughts from the others on here.

Really?

What was the technique?

This is why although I've heard that PSA usually takes between 1.5-1.8mg/kg over the entire procedure - I just like to go slow and steady.

Not sure if I'm very comfortable with 1mg/kg slug then 0.5mg/kg boluses... I'd rather give less because you can't take it away but you can always add more.

 

[la gringa]

haven't been allowed to use propofol for moderate sedation since residency... so i'm terribly out of practice.

 

[Mighty Mouse]

In residency we were able to use it. I would push 30mg bolus, and then an additional 10mg q30 seconds. Found that sometimes we wouldn't wait long enough for the meds to kick in and we often seemed to overshoot by 1-2 10mg hits. Also, I found that the patient's who went apneic didn't do so until the procedure was over and their catecholamine surge from pain was gone. So when everyone is high-fiving because the shoulder is back in, that's when I am most vigilant in watching the patient.

Where I work now, we use etomidate, ketamine, or fentanyl/versed depending on the circumstance. i love ketamine on the right patient. i don't really like etomidate for procedural sedation. been having too many patients not sedated enough or experiencing myoclonic jerks that makes it hard to get the surrounding musculature relaxed enough to get the joint reduced

 

[WilcoWorld]

Weird case.. I was doing a procedure and a partner was sedating a pretty healthy 60 yr old. Long story short the guy becomes apneic but then we bag him and he just desats. Interestingly he wasnt fat etc. Nothing to make you think it would have been hard to bag. We were bagging wihtout much resistance but the guys sats dropped way down, then popped up to a still low number until he got tubed. I was wondering if the guy bronchospasmed or what. No ketamine.. just a straight propofol sedation. Wondering on thoughts from the others on here.

Any signs of anaphylaxis or propofol infusion syndrome? Would be a really odd case, but, then again, you said it was a weird case.

 

[EctopicFetus]

I was performing the procedure and a partner was in charge of the sedation. was weird. no signs of anaphylaxis. The guy starts to wake up post intubation (on a propofol gtt) so i decide just to extubate the dude. Havent extubated someone in the ED since residency.

 

[dchristismi]

Weird.

I tend to fall in the 40 to 60, then 20-20-20 camp, although if by 100 they aren't sedated, I increase by 40 or 60 at a time. Some people take a lot. Some people take a tiny amount.
I had a teen with a dislocated shoulder that took 340 mg.
I had a LOL with a hip out that only took 40.

 

[docB]

I usually do 25 at a time until they're out then 10 at a time to keep them down if I need to. With older people or people who I feel like I'm almost there on I will give 10 at a time while I'm getting there.

 

[AvocadoLover]

In young healthy adults I've always worked with 1 mg/kg bolus and 0.5 mg/kg PRN (usually needed about every 90-120 seconds). I've been at 25 cases using this dose and have never seen the need for respiratory assistance.

 

[southerndoc]

Are any of you using mini doses of succinylcholine for difficult to reduce dislocations/fractures?

 

[pinipig523]

Are any of you using mini doses of succinylcholine for difficult to reduce dislocations/fractures?

Not me...

 

[pinipig523]

Weird.

I tend to fall in the 40 to 60, then 20-20-20 camp, although if by 100 they aren't sedated, I increase by 40 or 60 at a time. Some people take a lot. Some people take a tiny amount.
I had a teen with a dislocated shoulder that took 340 mg.
I had a LOL with a hip out that only took 40.

How long do you wait between mini boluses?

I assume 1 to 2 minutes...

 

[tegs15]

Me neither.

Although since our attendings have started doing scheduled sedations for outpt MRIs we have started using newer approaches. Yesterday I used ketafol (1/2 propofol and ketamine) for sedation during a trauma for a shoulder dislocation/fracture in a adolescent male. It was smooth like butter!

 

[xaelia]

Had an anesthesia attending come down and push propofol on her 60-odd year old father with a Colles'. Also placed his IV when our nurses had trouble. Gave 150mg to the 90kg patient. Needed a little chin lift and stimulation. A little more aggressive than I go, so it was interesting to see their comfort level with it.

Are any of you using mini doses of succinylcholine for difficult to reduce dislocations/fractures?

Neat idea - any links to literature describing its use?

 

[pinipig523]

Had an anesthesia attending come down and push propofol on her 60-odd year old father with a Colles'. Also placed his IV when our nurses had trouble. Gave 150mg to the 90kg patient. Needed a little chin lift and stimulation. A little more aggressive than I go, so it was interesting to see their comfort level with it.



Neat idea - any links to literature describing its use?

Good to know... the guy is gave a slug and called it a day.

 

[Birdstrike]

.

 

[AlmostJesus]

I had a patient while I was on clinicals in a small ED for my paramedic program. We gave him 50mg of morphine IV and 10mg of Versed and we couldnt get him relaxed enough to get his shoulder reduced.
Gave him some propofol and bam, back in. I am a firm believer in propofol now.
The guy was opioid dependent and took opioids on a regular basis for some problem with his shoulder joints. I suppose he could have just been seeking.
Is propofol your solution to seekers with dislocations?

 

[Hamhock]

I had a patient while I was on clinicals in a small ED for my paramedic program. We gave him 50mg of morphine IV and 10mg of Versed and we couldnt get him relaxed enough to get his shoulder reduced.
Gave him some propofol and bam, back in. I am a firm believer in propofol now.
The guy was opioid dependent and took opioids on a regular basis for some problem with his shoulder joints. I suppose he could have just been seeking.
Is propofol your solution to seekers with dislocations?

What?

First, I would say versed and morphine is a poor choice for "procedural sedation" in any case -- but especially in an opioid abuser.

Second: many shoulders need less procedural sedation and more patience...or someday, regional anesthesia (for the opioid abusers).

Third: Propofol is a great drug...but I think this thread is starting to lean towards the idea of increasing propofol if the patient "isn't down"...whereas I would argue that often the problem is that there is too little analgesia...if there is sufficient pain control, then propofol often works great...however, I too often see no or too little analgesia treated with induction doses/general anesthesia doeses of propofol.

[Admittedly, I nearly every time I do procedural sedation try for brief general anesthesia; but I also provide analgesia]

HH

 

[deleted109597]

50mg of morphine? Good lord, I can hear the nurses screaming "its my license" from South Dakota.



Speaking of which, even though that statement is the party line for RNs, has anyone here seen any nurse lose their license for anything other than diversion of drugs? Hell, I've seen them kill people, give flat out wrong medications, and all sorts of royal screwups, but none of them ever lost their license for that.



Also, for the OP, I bolus milk of amnesia at 1mg/kg unless they're old. After the 1mg/kg, I go to a 0.5mg/kg push, and then titrate from there based on response. I gave a guy 400mg the other day.

 

[Hamhock]

I bolus morphine at 1mg/kg unless they're old. After the 1mg/kg, I go to a 0.5mg/kg push, and then titrate from there based on response. I gave a guy 400mg the other day.

Is this a decimal problem or sarcasm?

I don't know which.

HH

 

[deleted109597]

I meant propofol. The morphine in the prior post stuck in my brain.

 

[AlmostJesus]

What?

First, I would say versed and morphine is a poor choice for "procedural sedation" in any case -- but especially in an opioid abuser.

Second: many shoulders need less procedural sedation and more patience...or someday, regional anesthesia (for the opioid abusers).

Third: Propofol is a great drug...but I think this thread is starting to lean towards the idea of increasing propofol if the patient "isn't down"...whereas I would argue that often the problem is that there is too little analgesia...if there is sufficient pain control, then propofol often works great...however, I too often see no or too little analgesia treated with induction doses/general anesthesia doeses of propofol.

[Admittedly, I nearly every time I do procedural sedation try for brief general anesthesia; but I also provide analgesia]

HH

They did try a block to no avail before the propofol
Outside of the cities where they have the volume for EM docs, in my experience, most of the small towns usually do versed and fentanyl first. Most of the doctors do not feel comfortable with giving propofol and sometimes anesthesia isnt immediately available (Some areas Ive worked, its 60+ minutes away). Thus, it is easier to go the versed/fentanyl route.
For the dude I mentioned, we tried the versed and morphine first, then we called anesthesia, they tried a block then did the propofol.

 

[pinipig523]

Tried it again tonight... propofol'd a guy with a humerus fracture.

SUPER smooth... I think I have it figured out for myself.

I really like going slow but ramping it up. 40mg x1 then 20mg q1-2min until sedation. This was on an 80kg man, etoh drinker.

Super smooth protocol methinks.

 

[drmwvr]

I must say, I'm quite amazed at the discussion of administration technique with very little mention of the specific procedures associated with said techniques. Varying levels of stimulation requires varying levels of "sedation". Propofol is not by any means a one size fits all agent. I would caution my colleagues here to take into account what they exactly they mean to do to a patient as a prerequisite to formulating a "sedation" plan, rather than going with a formulaic recipe that guarantees an obtunded subject regardless of the history or procedure. Good luck, Chaps!

 

[pinipig523]

Did another procedural sedation today.

Dx: Nail via nail gun into the patella, 80kg guy

Love propofol. Did my usual 60 + 20 + 20 + 20 + 20 bit...

So smooth, ortho loved it, I loved it. Guy woke up in 5 minutes and was elated that the nail was pulled out and he had no issues.

I'm a believer of propofol now. I like it much better than etomidate, ketamine, versed/fentanyl.

 

[WilcoWorld]

I must say, I'm quite amazed at the discussion of administration technique with very little mention of the specific procedures associated with said techniques. Varying levels of stimulation requires varying levels of "sedation". Propofol is not by any means a one size fits all agent. I would caution my colleagues here to take into account what they exactly they mean to do to a patient as a prerequisite to formulating a "sedation" plan, rather than going with a formulaic recipe that guarantees an obtunded subject regardless of the history or procedure. Good luck, Chaps!

Point taken, but that's where the titration comes in.

 

[Apollyon]

I must say, I'm quite amazed at the discussion of administration technique with very little mention of the specific procedures associated with said techniques. Varying levels of stimulation requires varying levels of "sedation". Propofol is not by any means a one size fits all agent. I would caution my colleagues here to take into account what they exactly they mean to do to a patient as a prerequisite to formulating a "sedation" plan, rather than going with a formulaic recipe that guarantees an obtunded subject regardless of the history or procedure. Good luck, Chaps!

I've read this post many times now, and the only thing I get is that you really aren't saying anything, or at least anything specific. Humerus fracture, nail to the patella, and dislocated shoulder are much more than "very little mention" of which procedures. At the same time, what do you mean "specific procedures associated with said techniques"? Procedural sedation stands on its own - that's why it's supposed to be done by a second doctor.

I tried to simplify your second to last sentence, but I can't. What you're saying is "make a plan - formulate a plan, rather than going with a formula", if I read it correctly. What you say, though, goes directly in the face of what everyone else has written. And what is your alternative to 1mg/kg? What others have written is that is no guarantee of an obtunded patient. I certainly don't think dchristismi's teen that took 340mg weighed 749 pounds, and the third post in the thread said that that person didn't even use calculations, titrating to effect.

If someone starts at 50 or 60, and goes up as needed, then, for that person's experience, that seems reasonable. If that 50 or 60 caused hypopnea or apnea, then the operator overshot, and can plan accordingly next time. Are you arguing with that?

Either that, or you are quite very easily amazed.

 

[DrQuinn]

For all adults, I do 40 mg, then boluses of 20. Never ever had a problem with it.

One of my best buds is an EMRAP junkie. he tried the ketofol x 3, 2 of the times the patient went apneic. Doc is way smarter than me, so he didn't F it up. Obviously anecdotal but to me, i've never had an oversedation with propofol, so "if it ain't broke don't fix it."
Q

 

[southerndoc]

Am I the only one that doesn't get concerned when a patient gets apneic from it? I just bag them until they wake up. I've only had it happen once. Had it occur twice where I had to use a jaw thrust to get them to continue breathing.

 

[Birdstrike]

.

 

[docB]

Am I the only one that doesn't get concerned when a patient gets apneic from it? I just bag them until they wake up. I've only had it happen once. Had it occur twice where I had to use a jaw thrust to get them to continue breathing.

That's the beauty of propofol, it wears off so quickly you're likely to be able to bag them through any trouble. You should assess their airway ahead of time of course, and be comfortable they would be easy to bag if needed. If you're not skilled in airway, or comfortable managing an airway, you should not use propofol. If you are, its a great drug.

I agree but it helps to be really comfy with BLS airway management. If your only BVM experience is as a prelude to intubation then I can see people getting anxious when they have to manage their procedural sedation patients with it.

 

[turkeyjerky]

For all adults, I do 40 mg, then boluses of 20. Never ever had a problem with it.

One of my best buds is an EMRAP junkie. he tried the ketofol x 3, 2 of the times the patient went apneic. Doc is way smarter than me, so he didn't F it up. Obviously anecdotal but to me, i've never had an oversedation with propofol, so "if it ain't broke don't fix it."
Q

Did he push it too fast? My understanding is that rapid administration of ketamine can lead to transient apnea.

 

[always.chillin]

Bumping this thread to get some thoughts. Let’s say you have a hip dislocation. Patient absolutely needs sedation for reduction. After a total of 2.5 mg/kg of propofol patient still not sedated enough. You then add 1 mg/kg of ketamine. Still not sedated enough and reduction fails. At this point, you’re nervous to give more. Do you just admit the patient to have OR reduction with anesthesia or intubate the patient yourself and reduce? I’ve had this happen a few times. I always just admit and have it done in OR and after reviewing the chart anesthesia has always intubated the patient for reduction. The problem is ortho always gets upset and tells me “patient not sedated enough.” I frankly don’t have time to intubate a patient for a reduction and try to extubate in the ER.

 

[HoosierdaddyO]

Bumping this thread to get some thoughts. Let’s say you have a hip dislocation. Patient absolutely needs sedation for reduction. After a total of 2.5 mg/kg of propofol patient still not sedated enough. You then add 1 mg/kg of ketamine. Still not sedated enough and reduction fails. At this point, you’re nervous to give more. Do you just admit the patient to have OR reduction with anesthesia or intubate the patient yourself and reduce? I’ve had this happen a few times. I always just admit and have it done in OR and after reviewing the chart anesthesia has always intubated the patient for reduction. The problem is ortho always gets upset and tells me “patient not sedated enough.” I frankly don’t have time to intubate a patient for a reduction and try to extubate in the ER.

Screw ortho… they won’t be at your trial when you’re getting sued for something going wrong. Let them deal with it, admit, case closed, go home with your pride and license intact!!!

 

[skougess]

Bumping this thread to get some thoughts. Let’s say you have a hip dislocation. Patient absolutely needs sedation for reduction. After a total of 2.5 mg/kg of propofol patient still not sedated enough. You then add 1 mg/kg of ketamine. Still not sedated enough and reduction fails. At this point, you’re nervous to give more. Do you just admit the patient to have OR reduction with anesthesia or intubate the patient yourself and reduce? I’ve had this happen a few times. I always just admit and have it done in OR and after reviewing the chart anesthesia has always intubated the patient for reduction. The problem is ortho always gets upset and tells me “patient not sedated enough.” I frankly don’t have time to intubate a patient for a reduction and try to extubate in the ER.

There’s not a dose I’m uncomfortable with. Patients seem to sometimes have wildly different dose responses to propofol. If I’m pushing propofol and the dude is apneic even while attempting reduction and it doesn’t work, then yeah that means they need to go to the OR.

The time to avoid going as hard as needed is BEFORE the procedure if you feel it is too high risk to do in the ER. Once you decide to start, go full beans.

 

[Apollyon]

There’s not a dose I’m uncomfortable with. Patients seem to sometimes have wildly different dose responses to propofol. If I’m pushing propofol and the dude is apneic even while attempting reduction and it doesn’t work, then yeah that means they need to go to the OR.

The time to avoid going as hard as needed is BEFORE the procedure if you feel it is too high risk to do in the ER. Once you decide to start, go full beans.

It was over 15 years ago, so I'm going from memory. One of our first mods told a story of giving a young dude 300mg of prop, with NOTHING. No response at all.

 

[BoardingDoc]

Bumping this thread to get some thoughts. Let’s say you have a hip dislocation. Patient absolutely needs sedation for reduction. After a total of 2.5 mg/kg of propofol patient still not sedated enough. You then add 1 mg/kg of ketamine. Still not sedated enough and reduction fails. At this point, you’re nervous to give more. Do you just admit the patient to have OR reduction with anesthesia or intubate the patient yourself and reduce? I’ve had this happen a few times. I always just admit and have it done in OR and after reviewing the chart anesthesia has always intubated the patient for reduction. The problem is ortho always gets upset and tells me “patient not sedated enough.” I frankly don’t have time to intubate a patient for a reduction and try to extubate in the ER.

If the patient isn't adequately sedated with 2.5mg/kg of prop and 1mg/kg of (I assume IV not IM) ketamine, they need to be admitted and likely intubated for the procedure in the OR. If you're intubating patients in the ED for the purpose of doing a procedure, you're doing something wrong.

 

[DrDrummer]

Bumping this thread to get some thoughts. Let’s say you have a hip dislocation. Patient absolutely needs sedation for reduction. After a total of 2.5 mg/kg of propofol patient still not sedated enough. You then add 1 mg/kg of ketamine. Still not sedated enough and reduction fails. At this point, you’re nervous to give more. Do you just admit the patient to have OR reduction with anesthesia or intubate the patient yourself and reduce? I’ve had this happen a few times. I always just admit and have it done in OR and after reviewing the chart anesthesia has always intubated the patient for reduction. The problem is ortho always gets upset and tells me “patient not sedated enough.” I frankly don’t have time to intubate a patient for a reduction and try to extubate in the ER.

I've seen people run into this before. I'm not really sure why people aren't comfortable giving more Propofol to someone who is clearly demonstrating tolerance. Make sure your IV is good and you're not creating a lump of propofol in their blubber bicep, check to make sure you have all the airway stuff you need, consider multi-modal treatment (e.g. you can give something reversible like Fentanyl or Midazolam if you're really nervous) and uptitrate the Propofol. Or if you're uncomfortable and they're in house, ask anesthesia to come to the ER and push meds for you - it's not unreasonable.

It's also always possible you're trying to reduce a hip with a constrained liner. Seen that one several times too. At the end of the day, sending a difficult hip reduction to the OR is not a big deal. A shoulder on the other hand, I'd feel like I could've probably done better.

To answer the OP question from a million years ago with an answer I haven't seen yet, my starting bolus is 100 minus their age. Only half-kidding. I sedate a lot of geriatric patients with Propofol for cardioversions at my job and I have found that for the geriatric crew that isn't a bad formula.

 

[RustedFox]

To answer the OP question from a million years ago with an answer I haven't seen yet, my starting bolus is 100 minus their age. Only half-kidding. I sedate a lot of geriatric patients with Propofol for cardioversions at my job and I have found that for the geriatric crew that isn't a bad formula.

Age + BUN = lasix dose.
100 - Age = propofol dose.

 

[Janders]

I’ve emptied a 200mg bottle into a 30kg child in a couple minutes and had them screaming at me… metabolism is weird. I tend to dose a little low with my first dose of prop and stair step into good sedation on the riskier cases. Takes a minute but I don’t feel unsafe going high if it’s necessary.

But yeah if I’m deep in propofol and ketamine and not winning… punt. Punt. Punt. Don’t be a hero. No one will defend you if things go sideways. Hip reductions do occur in super sick super old people, and I’ve only heard of one time when we called anesthesia and they still did an Ed bedside reduction. Every other time the go to the OR. Intubate. Paralyze. At least once or twice still have complications.

 

[Janders]

Age + BUN = lasix dose.
100 - Age = propofol dose.

Eh sounds good but I’m more a 0.5mg/kg guy for elderly propofol sedation. 40mg gets 80 year olds in a great spot where I doubt 20mg will work. Maybe I’ll try microdosing...

 

[southerndoc]

Bumping this thread to get some thoughts. Let’s say you have a hip dislocation. Patient absolutely needs sedation for reduction. After a total of 2.5 mg/kg of propofol patient still not sedated enough. You then add 1 mg/kg of ketamine. Still not sedated enough and reduction fails. At this point, you’re nervous to give more. Do you just admit the patient to have OR reduction with anesthesia or intubate the patient yourself and reduce? I’ve had this happen a few times. I always just admit and have it done in OR and after reviewing the chart anesthesia has always intubated the patient for reduction. The problem is ortho always gets upset and tells me “patient not sedated enough.” I frankly don’t have time to intubate a patient for a reduction and try to extubate in the ER.

I don't care if a patient needs 1,000 mg of propofol. It's not the amount but the patient response that determines my comfort zone. If I give them 40 mg and they're apneic and difficult to bag, then I abort the procedure. I've once given 600 mg to get someone sedated.

FWIW, I also combine with either midazolam, fentanyl, and/or ketamine.

 

[Radetzky]

Bumping this thread to get some thoughts. Let’s say you have a hip dislocation. Patient absolutely needs sedation for reduction. After a total of 2.5 mg/kg of propofol patient still not sedated enough. You then add 1 mg/kg of ketamine. Still not sedated enough and reduction fails. At this point, you’re nervous to give more. Do you just admit the patient to have OR reduction with anesthesia or intubate the patient yourself and reduce? I’ve had this happen a few times. I always just admit and have it done in OR and after reviewing the chart anesthesia has always intubated the patient for reduction. The problem is ortho always gets upset and tells me “patient not sedated enough.” I frankly don’t have time to intubate a patient for a reduction and try to extubate in the ER.

Without being there I would bet that your patient was plenty sedated; sounds more like a muscle relaxation problem!

 

[watermanMD]

Who TF are y’all’s patients? I rarely have to give more than 1mg/kg. I commonly start at 0.5 and achieve adequate sedation for a quick ortho procedure. I can’t recall the last time I’ve had to redose past 1.5mg/kg total.

 

[RustedFox]

Who TF are y’all’s patients? I rarely have to give more than 1mg/kg. I commonly start at 0.5 and achieve adequate sedation for a quick ortho procedure. I can’t recall the last time I’ve had to redose past 1.5mg/kg total.

A few years back I was sedating a shoulder reduction:

10mg etomidate.
10mg etomidate again.
1mg/kg ketamine.
1mg/kg ketamine again.

Propofol.

Guy made it all the way thru to propofol with limited if any effect.