Moderator EMEDPA Posted March 24, 2022 Moderator Share Posted March 24, 2022 Propofol is a great medication, but I am seeing it used inappropriately more and more often, typically by younger providers. Propofol is not a great option for sedation or post-intubation in someone who is already hypotensive. Recent examples: 1. septic pt, looking bad and requiring intubation. Propofol started post-intubation, worsening an already borderline bp. Next step? Levophed that they likely would not have needed otherwise. 2. Pt requiring emergent cardioversion. hypotensive with CP. Given propofol and requiring post-procedural pressors.... People, please consider alternatives like etomidate, Vec/versed, etc in already hypotensive patients. steps off soapbox.... 2 Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted March 25, 2022 Share Posted March 25, 2022 Agreed. Versed/fentanyl for procedural sedation. Ketamine possibly plus fentanyl for post intubation sedation with additional paralysis as needed. Quote Link to comment Share on other sites More sharing options...
MediMike Posted March 25, 2022 Share Posted March 25, 2022 I've noticed a worrisome trend in the more "seasoned" providers to use versed rather than propofol or dexmedetomidine... It is better to use propofol and norepinephrine than have a patient on a midazolam infusion. Studies have consistently shown longer length of stay, longer time on the vent, more delirium and multiple observational studies have shown significantly higher mortality. Your 2nd example? 100% agree. Can't stand propofol being used for induction or conscious sedation in the critically ill as there are better options. For sedation in our intubated patients I prefer: Precedex Propofol Ketamine A large hammer Midazolam Slightly tongue-in-cheek of course (the hammer is likely more effective than the ketamine) Quote Link to comment Share on other sites More sharing options...
Moderator LT_Oneal_PAC Posted March 26, 2022 Moderator Share Posted March 26, 2022 On 3/25/2022 at 7:01 AM, MediMike said: I've noticed a worrisome trend in the more "seasoned" providers to use versed rather than propofol or dexmedetomidine... It is better to use propofol and norepinephrine than have a patient on a midazolam infusion. Studies have consistently shown longer length of stay, longer time on the vent, more delirium and multiple observational studies have shown significantly higher mortality. Your 2nd example? 100% agree. Can't stand propofol being used for induction or conscious sedation in the critically ill as there are better options. For sedation in our intubated patients I prefer: Precedex Propofol Ketamine A large hammer Midazolam Slightly tongue-in-cheek of course (the hammer is likely more effective than the ketamine) Eh? A hammer more effective than ketamine? While I like etomidate in my quick cardioversions that are going home, ketamine in the thing to beat in most situations. i won’t disagree that precedex is better for sedation for intubation, but I can’t get it and the helicopters here won’t stock it for transport. Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 26, 2022 Author Moderator Share Posted March 26, 2022 I like fentanyl and etomidate for short procedures and vec/versed postintubation. I typically do 10 mg vec and 5 mg versed IV push (not infusion) every 45 min. Easy to do. Great BP profile. Simple and no pumps. Medics hate transporting multiple drips and all of our intubated patients leave by EMS or in a helicopter. I only have used precedex for alcohol withdrawal not responding well to a boatload of benzos. PS ketamine is the bomb. Love it. 1 Quote Link to comment Share on other sites More sharing options...
MediMike Posted March 26, 2022 Share Posted March 26, 2022 I enjoy ketamine for procedural use, infusions for sedation in ICU not so much. If your medical hate transporting multiple drips they should probably get a different job, that's what CCT is all about! (That and untangling the mess the ED made of the lines ) 1 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 27, 2022 Author Moderator Share Posted March 27, 2022 I like ketamine for a few things: brief peds sedations adult sedations mixed with propofol (Ketofol) Low dose 0.1-0.2 mg/kg to help bronchodilate and relax folks on bipap Induction for resp arrest intubations at 2 mg/kg. Our medics are 911 medics who get stuck doing CCT. Very few people actually want to do it. I know I didn't when I was a 911 medic. They took away my syringe pumps! If I have to do drips, don't give me those multi-channel IV pumps, give me good, old-fashioned syringe pumps. Those I can make work https://www.terumo-europe.com/en-emea/products/terufusion™-syringe-pump-(smart) 1 1 Quote Link to comment Share on other sites More sharing options...
Moderator LT_Oneal_PAC Posted March 27, 2022 Moderator Share Posted March 27, 2022 7 hours ago, MediMike said: I enjoy ketamine for procedural use, infusions for sedation in ICU not so much. If your medical hate transporting multiple drips they should probably get a different job, that's what CCT is all about! (That and untangling the mess the ED made of the lines ) I think it’s more about getting people to stock it. The nearest level one also does not carry it in the ED (or didn’t when I was there) so they don’t see the point in having it when it will have to be switched, so ours won’t stock it because the flight crew will switch it. Quote Link to comment Share on other sites More sharing options...
MediMike Posted March 27, 2022 Share Posted March 27, 2022 11 hours ago, LT_Oneal_PAC said: I think it’s more about getting people to stock it. The nearest level one also does not carry it in the ED (or didn’t when I was there) so they don’t see the point in having it when it will have to be switched, so ours won’t stock it because the flight crew will switch it. Sorry, that was a response to Emed re: using repeated pushes of midazolam rather than an infusion of something! Quote Link to comment Share on other sites More sharing options...
Moderator LT_Oneal_PAC Posted March 28, 2022 Moderator Share Posted March 28, 2022 11 hours ago, MediMike said: Sorry, that was a response to Emed re: using repeated pushes of midazolam rather than an infusion of something! Ah, I thought for some reason you were talking about precedex infusions. My bad! 1 Quote Link to comment Share on other sites More sharing options...
dphy83 Posted March 31, 2022 Share Posted March 31, 2022 On 3/26/2022 at 1:26 PM, EMEDPA said: I only have used precedex for alcohol withdrawal not responding well to a boatload of benzos. No phenobarb? Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 31, 2022 Author Moderator Share Posted March 31, 2022 24 minutes ago, dphy83 said: No phenobarb? never. we don't even stock it. Quote Link to comment Share on other sites More sharing options...
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