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 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