Transcript Safe Propofol Administration in the ED

Safe Propofol Administration
Developed by
Kelly Banasky, RN, BSN
Educator, Emergency Services
Explanation of Propofol
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
Mechanism of Action
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
Propofol (Diprivan)
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
Common Adverse Effects
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
Serious Adverse Effects
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
Drug Interactions
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)
Contraindications and Warnings
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.
Issues of Sterility and Administration
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
Approved Uses for Propofol
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.
Equipment and Requirements
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
Monitoring
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
Toxicology concerns
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
Indications for administration to the vented patient
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
Dosing Guidelines for the Vented Patient
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
Monitoring Requirements in the Vent Patient
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
Indication for use in Procedural Sedation
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
Required Assessments prior to Procedural Sedation
All info must be complete
Baseline assessment by RN
of the following:
• HR
• Cardiac Rhythm
• BP
• SPO2
• RR
• Pain Score
• LOC
Co-Morbid Conditions
Medications the pt takes
ASA Score
Date
Required signatures of
Physician and RN
Pre-Sedation Aldrete Score
(Back of form)
If DC is anticipated,
evaluate/screen for
responsible person to drive
pt home.
Document all findings
Procedural Sedation Monitoring Requirements
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
1. Physician (resident) performing the procedure
2. Attending physician whose only responsibility is to monitor
propofol administration and the patient’s airway
3. Registered Nurse with ACLS certification
Dosing for procedural sedation
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.
Breakdown of Dosing for Procedural Sedation
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
Documentation for Procedural Sedation
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
Points to Consider
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
References
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