Propofol is a short acting hypnotic: the mechanism of action has not been well defined



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Propofol is a short acting hypnotic: the mechanism of action has not been well defined

  • Propofol is a short acting hypnotic: the mechanism of action has not been well defined

  • Propofol has more pronounced hemodynamic effects than other IV agents

    • Arterial blood pressure readings decrease as much as 30%
    • Hypotensive effects are FURTHER potentiated by opioid analgesics.
  • Resembles milk in color, is white and solid

  • Is an emulsion that is stored in glass bottles and requires vented tubing for use in continuous intra-venous administration



Decreases cerebral blood flow, cerebral metabolic O2 consumption, and ICP & increases cerebrovascular resistance.

  • Decreases cerebral blood flow, cerebral metabolic O2 consumption, and ICP & increases cerebrovascular resistance.

  • Has NO analgesic properties

  • Propofol has anti-emetic properties which results in less nausea & vomiting than other anesthetic agents

  • Half-life ranges from 3 to 12 hours

  • Is a respiratory depressant, producing apnea > 60 seconds

  • Extreme caution must be exercised when using Propofol.

  • There is much debate between American College of Emergency Physicians (ACEP ) & American Society of Anesthesiologists (ASA) regarding Propofol use in the ED

  • Gained recent notoriety with the death of pop-star Michael Jackson



CRITICAL POINT: When administering Propofol or any conscious sedation agent, the RN monitoring the patient is to focus solely on that patient until return to baseline.

  • CRITICAL POINT: When administering Propofol or any conscious sedation agent, the RN monitoring the patient is to focus solely on that patient until return to baseline.

  • Who can administer Propofol:

    • Anesthesiologists
    • Physicians
    • CRNA
    • Emergency Department ACLS certified RN’s who have completed the Moderate Conscious Sedation Exam at GCH
    • RN must be eligible to work in Trauma
  • Where can Propofol be administered:

    • Surgical or Endo Suites
    • ED in AC/Trauma or Ortho room


Dermatological: Injection site reactions

  • Dermatological: Injection site reactions

  • Gastrointestinal: Nausea and Vomiting (have suction readily available

  • Musculoskeletal: Involuntary movement, (can be severe enough to mimic a seizure)

  • KEYPOINT: Patient’s with compromised cardiac function, Hypovolemia, or abnormally low vascular tone (SEPSIS) may be more susceptible to hypotension



Cardiovascular: Bradyarrhythmia, heart failure, hypotension, decreased cardiac output

  • Cardiovascular: Bradyarrhythmia, heart failure, hypotension, decreased cardiac output

  • Gastrointestinal: Pancreatitis

  • Immunologic: Anaphylaxis

  • Neurologic: Seizure

  • Renal: Acute Renal Failure

  • Reproductive: Priapism

  • Respiratory: Apnea, Respiratory Acidosis

  • Other: Bacterial Septicemia, Propofol adverse reaction, Infusion Syndrome



Major

  • Major

  • Bupivacaine may increase the hypnotic effect of Propofol

  • Lidocaine (Intramuscular) increases the hypnotic effect of Propofol

  • St. John’s Wort in combo with Propofol can result in hypotension and delayed emergence from anesthesia (evaluate patient for alternative therapies)

  • Moderate

  • Succinylcholine (probable)



Patients with a hypersensitivity to Propofol or its components should not receive this medication

  • Patients with a hypersensitivity to Propofol or its components should not receive this medication

  • Allergies to eggs, egg products, soybeans or soy products

  • A complete nursing assessment must be made prior to administration of Propofol.



After 12° from spiking vial, DC tubing and any unused portions of propofol

  • After 12° from spiking vial, DC tubing and any unused portions of propofol

  • Propofol emulsion has NO preservatives and is capable of supporting rapid growth of microorganisms

  • Strict aseptic technique must always be maintained during handling of propofol injectable emulsion

  • If emulsion is transferred to a syringe, it must be used within 6 hours

  • Flush the IV line every 6 hours and at the end of the anesthetic procedure

  • Do NOT dilute Propofol



Sedation for mechanically ventilated patients who are to be admitted to a Critical Care Bed

  • Sedation for mechanically ventilated patients who are to be admitted to a Critical Care Bed

  • Procedural Sedation, when Etomidate or first line agents are not effective.

  • KEYPOINT: Other uses for Propofol in the ED have not been approved by the Pharmacy and Therapeutic (P & T) committee at GCH.



Cardiac monitoring

  • Cardiac monitoring

  • Continuous pulse-oximetery

  • Working/Full oxygen source

  • Working suction readily available

  • Crash cart immediately accessible

  • LifePak 12 or 20 immediately accessible (may be applied for procedural sedation and for monitoring)

  • Moderate conscious sedation flow sheet for procedural sedation

  • Sigma Spectrum Smart pump if for vented patient



All patients receiving propofol MUST be monitored for:

  • All patients receiving propofol MUST be monitored for:

    • Vital signs
    • Neurologic function
    • Cardiac and Respiratory Rate
    • S & S of bacterial sepsis (Fever, Chills & Body aches)
  • Be prepared for rescue for patients receiving Propofol for procedural sedation

    • Must be able to manage a compromised airway immediately
    • Oxygenation and ventilation must be readily available
    • If over-sedated, STOP propofol administration IMMEDIATELY, stimulate breathing


Overdose can occur by way of cardio-respiratory depression. Safety is the primary concern when administering this drug.

  • Overdose can occur by way of cardio-respiratory depression. Safety is the primary concern when administering this drug.

  • Overdose Treatment:

  • Support and manage the airway

  • Treat hypotension with IV NS 10-20 mL/kg; consider dopamine or norepinephrine

  • Treat Ventricular Arrhythmia: Lidocaine, Amiodarone, Procainamide, and Cardioversion if unstable

  • Treat Acidosis: Monitor ABG, administer Sodium Bicarbonate at 1-2mEq/kg q 1-2 hours if pH is < 7.1



Must be between the ages of 18 & 65

  • Must be between the ages of 18 & 65

  • Mechanically ventilated & admitted/waiting to a critical care bed

  • Continued agitation despite administration of a total of 8mg of Ativan (lorazepam) in a one hour period

    • Only Exception to this is for patients who are undergoing therapeutic hypothermia
  • Agitation in patients with a documented benzodiazepine allergy

  • Patient’s pain is adequately controlled



Initial dose: 5 mcg/kg/min IV infusion for at least 5 minutes

  • Initial dose: 5 mcg/kg/min IV infusion for at least 5 minutes

  • Titration: can be titrated in 5-10mcg/kg/min increments to achieve the desired level of sedation, up to a maximum dose of 80mcg/kg/min

  • KEYPOINTS:

    • Allow 5 minutes minimum between titrations to assess drug effects
    • Do NOT administer bolus doses
    • Lower doses may be needed in the following patients
      • Elderly or debilitated
      • Patients who have received large doses of narcotics


Breakdown of Dosing for Mechanically Vented Patients

  • Titration

    • 5mcg/kg/min (0.3mg/kg/hour) for 5 minutes
    • Allow a minimum of 5 minutes between dose adjustments
    • 5-10mcg/kg/min (0.3-0.6 mg/kg/hour) increments
    • Max dose of 80mcg/kg/min
  • The Sigma Spectrum Pump must be used for administration

    • The pump programs Propofol at mcg/kg/hour
    • Do NOT attempt to bypass safety protocols
    • Utilize the smart pump features.
  • Dosing available in Pharmacy

    • Large bottle
    • 1000mg/100mL bottle
    • 10mg/mL


Continuous cardiac monitoring

  • Continuous cardiac monitoring

  • Continuous pulse oximetry

  • Blood Pressures:

    • Every 5 minutes for the first 30 minutes of Propofol sedation and until the patient is stable
    • Every 30 minutes after patient is stable (minus 30 minutes from induction)
  • Evaluate the level of sedation and assess CNS functions throughout infusion to determine the minimum dose of Propofol required for sedation



The patient must meet all of the following criteria

  • The patient must meet all of the following criteria

    • Must be > 18 years of age
    • Requires procedural sedation and Etomidate or first line agents are not effective
    • Patient MUST be hemodynamically stable
    • DO NOT USE in patients with a SBP < 100mmHg
    • Informed consent MUST be obtained by the physician prior to administration of propofol
  • The Baseline RN assessment must be completed prior to administering propofol



All info must be complete

  • All info must be complete

  • Baseline assessment by RN of the following:

    • HR
    • Cardiac Rhythm
    • BP
    • SPO2
    • RR
    • Pain Score
    • LOC


Continuous cardiac monitoring

  • Continuous cardiac monitoring

  • Continuous pulse oximetry

  • Continuous oxygen administration

  • Monitoring of respiratory rate

  • A MINIMUM of 3 health care professionals must be present in the room at the time of the procedure and propofol administration

    • Physician (resident) performing the procedure
    • Attending physician whose only responsibility is to monitor propofol administration and the patient’s airway
    • Registered Nurse with ACLS certification


Initial Dose: 0.5 – 1 mg/kg* over 3-5 minutes

  • Initial Dose: 0.5 – 1 mg/kg* over 3-5 minutes

  • May repeat dose of 0.5mg/kg 1 time after 5 minutes if necessary

  • Do NOT administer via continuous infusion

  • KEYPOINT: Consider using lower end of dosing for those patients > 65 years of age as health may affect actions of drug.

  • KEYPOINT: VS & assessment are to occur every 2.5 to 5 minutes with documentation every 5 minutes.



Procedural Sedation Patients

  • Procedural Sedation Patients

    • Initial dose 0.5mg – 1mg/kg over 3-5 minutes
    • May be repeated only once
    • NOT for continuous infusion
  • Dosing Available in Pharmacy

    • Small Bottle
    • 200mg/20mL bottle
      • 10mg/mL


All meds & IVF administered (doses & times)

  • All meds & IVF administered (doses & times)

  • All interventions needed/required (i.e. O2, Suction, etc.)

  • Ongoing assessment including (every 2.5 – 5 minutes with documentation q 5 minutes:

    • HR
    • Cardiac Rhythm
    • BP
    • SPO2
    • RR
    • Pain Score
    • LOC


Hypnosis usually occurs within 40 seconds

  • Hypnosis usually occurs within 40 seconds

  • Duration of action is approximately 3 to 10 minutes

  • In the moderately sedated patient, the eyes may roll up/down, or close. The patient will be nonverbal, and may yawn

  • Propofol has NO analgesic properties!!!

    • Remember if the patient is in pain, treat the pain
    • If pain medication is to be administered, a short acting opioid may be used, but the propofol dose should be reduced
  • May be combined with a benzodiazepine (this will reduce propofol dose



Dunn, T., Mossop, D., Newton, A., Gammon, A. (2007) Propofol for procedural sedation in the emergency department Emergency Medicine Journal 2007; 24:459-461

  • Dunn, T., Mossop, D., Newton, A., Gammon, A. (2007) Propofol for procedural sedation in the emergency department Emergency Medicine Journal 2007; 24:459-461

  • Garden City Hospital, Department of Pharmacy, Propofol Administration in the Emergency Department Policy & Procedure

  • Garden City Hospital Moderate Conscious Sedation Competency

  • Garden City Hospital Pharmacy and Therapeutics Committee

  • Green, S., Krauss, B. (2008) Barriers to propofol use in Emergency Medicine Annals of Emergency Medicine October 2008 Vol. 52, No. 4 pp. 392-398

  • MICROMEDEX ® Healthcare Series DRUGDEX® Drug Point Summary: Propofol Retrieved Electronically on 05/19/2011



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