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Propofol In Pediatric Transport


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#1 cessnafelix

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Posted 04 February 2011 - 07:50 PM

Anyone using Propofol in PEDIATRIC transports? If so, do you have particular guidelines you use? Also if anyone has any RECENT research regarding this subject I would appreciate a point in the right direction. Im sure there's lots of data out there & dont want to reinvent the wheel. Any help much appreciated.

Felix
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#2 medicRT

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Posted 05 February 2011 - 03:41 AM

Anyone using Propofol in PEDIATRIC transports? If so, do you have particular guidelines you use? Also if anyone has any RECENT research regarding this subject I would appreciate a point in the right direction. Im sure there's lots of data out there & dont want to reinvent the wheel. Any help much appreciated.

Felix

This is a "my experience" type reply. Our team is neo to age 3, based out of large Paeds Hospital in Canada and we do not use Propofol on transport. I believe our multi age Paramedic teams do not "use" [ ie. give] it either (but may continue an existing infusion in adults only with MD order).

I think that the restriction comes from manufacturer's guideline (and I checked briefly at drugs.com) monograph whereby it references not advised for under 3 population for many applications.

I think there was also a time when the manufacturer advised restricting the use to Anaesthesia and Intensivists only.

just some thoughts.
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#3 Mike Mims

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Posted 05 February 2011 - 03:53 AM

Anyone using Propofol in PEDIATRIC transports? If so, do you have particular guidelines you use? Also if anyone has any RECENT research regarding this subject I would appreciate a point in the right direction. Im sure there's lots of data out there & dont want to reinvent the wheel. Any help much appreciated.

Felix

We use it on Adults only. Our Peds ED doesn't use it either.

As for the CC units in the Children's hospital, I'm not sure.......
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#4 overunder

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Posted 05 February 2011 - 08:43 AM

Our hospital uses it but it is restricted to in presence of physician due to rating as an anesthetic agent. So Team doesn't use, hospital does.
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#5 BrianACNP

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Posted 05 February 2011 - 02:08 PM

I don't have the references with me, but the main concern I've heard from our pediatric intensivist colleagues is the concern for propofol infusion syndrome with the use of propofol. I've been told that it's documented in the literature. Our PICU does not use propofol for sedation.


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#6 Travis Engel

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Posted 05 February 2011 - 08:10 PM

I don't have the references with me, but the main concern I've heard from our pediatric intensivist colleagues is the concern for propofol infusion syndrome with the use of propofol. I've been told that it's documented in the literature. Our PICU does not use propofol for sedation.


Brian


I worked for a large Pedi specialty team in Texas, and we did not use it. This decision was more for practical purposes though I believe. If you are using propofol and your line goes bad or the infusion stops for whatever reason, you have about 3 seconds to get you patient's sedation started again before they come unglued. With as many tenuous tubes and fragile IVs we encounter during pedi transport, the risk benefit was not there. Benzos did just fine for us and offered a little more cushion if we encountered IV issues or other infusion problems.

Now, as for the ICU, proposal drips were not uncommon. In that controlled environment, the risks went down considerably.

So in my mind, the risks for using propofol in peds transport had more to do with what could happen if your patient comes out of sedation, not necessarily the drug itself.
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#7 JLP

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Posted 05 February 2011 - 11:01 PM

many tenuous tubes and fragile IVs we encounter during pedi transport, the risk benefit was not there. Benzos did just fine for us and offered a little more cushion if we encountered IV issues or other infusion problems.

So in my mind, the risks for using propofol in peds transport had more to do with what could happen if your patient comes out of sedation, not necessarily the drug itself.


Hey Travis, if I can sidetrack this a bit - how often did you encounter paradoxical excitation in kids from using benzos - i.e. the pt has an excitatory response that competes with the sedation action of the benzos? I had only heard of this until I had a 13 years old developmentally delayed sepsis pt two years ago that got LESS sedated at the versed dose was increased, switched to a morphine infusion which solved things nicely. I kept meaning to check if this was related to the developmental issues, but never did...
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#8 cessnafelix

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Posted 05 February 2011 - 11:07 PM

Thanks for replies so far. We are looking at potentially using this drug, when it is already in use - which is frequently the case at outside hospitals where a teen has come in & is now a trauma, or post arrest etc. Also many pts are intubated for seizures & so our PICU would like to extubate quickly. We occasionally will have to switch the pt from an already running propofol drip, in order to then use benzos. If the IV / airway etc are fragile, we will often paralyse for transport. propofol infusion syndrome in children is documented to cause harm, but in prolonged infusions, which is not what we are looking at.

Felix
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#9 BrianACNP

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Posted 06 February 2011 - 05:06 AM

... propofol infusion syndrome in children is documented to cause harm, but in prolonged infusions, which is not what we are looking at.

Felix


True.....greater than 48 hours of infusion is typically the hallmark timeframe......may be an issue if you're picking up a patient with it already in place. I know that PRIS is the reason our peds intensivists tend to shy away from it.

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#10 Travis Engel

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Posted 06 February 2011 - 05:19 AM

Hey Travis, if I can sidetrack this a bit - how often did you encounter paradoxical excitation in kids from using benzos - i.e. the pt has an excitatory response that competes with the sedation action of the benzos? I had only heard of this until I had a 13 years old developmentally delayed sepsis pt two years ago that got LESS sedated at the versed dose was increased, switched to a morphine infusion which solved things nicely. I kept meaning to check if this was related to the developmental issues, but never did...


We did have some education on the paradoxical effects of benzos in peds, but it was a small part of a larger lecture relating to long term sedation of ICU patients. I have never seen it personally, but from what I understood it was seen in a small percentage of patients (maybe 4 if I can recall right?) and was generally related to high doses.

I know that quite a few of our developmentally delayed patients, especially Down's Syndrome, took large doses of medication in order to effect adequate sedation. I am talking 2-3 times the normal dose sometimes, and at a much higher frequency. We were warned that with these large doses, especially in these segments of patients, there was a higher incidence of the paradoxical action you mention. Could possibly explain why you saw it? Were you working with normal dosages?

Anyway, I guess to answer you question, I never saw it personally, but we were warned about it, which means it must not be too obscure.
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#11 Travis Engel

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Posted 06 February 2011 - 10:09 PM

Just wanted to add a little to my last post.

I talked with my wife who has been in the PICU for 9 years to get her opinion on the benzo issue. She said she has seen it maybe 3 times in 9 years, and she has given benzos to literally thousands of children. When she saw it she said the patients literally looked like they were on fire, coming unglued and out of control. It is a strange situation because your immediate reaction is to give another dose of sedation, until you realize what's happening.

Anyway, just wanted to add that.
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#12 JLP

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Posted 06 February 2011 - 10:53 PM

Just wanted to add a little to my last post.

I talked with my wife who has been in the PICU for 9 years to get her opinion on the benzo issue. She said she has seen it maybe 3 times in 9 years, and she has given benzos to literally thousands of children. When she saw it she said the patients literally looked like they were on fire, coming unglued and out of control. It is a strange situation because your immediate reaction is to give another dose of sedation, until you realize what's happening.

Anyway, just wanted to add that.


Thanks, I appreciate the follow-up. Your wife's scenario, that would have been...a little too interesting. Mine was a septic, seriously ill pt, already vented, high end of normal dosage, just as the dosage was increased he became LESS sedated, fighting the vent more, and more tachy. Switching him to a morph infusion settled him right down.
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#13 Grouse

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Posted 14 February 2011 - 06:16 AM

We do carry it and use it and many of our physicians seem to prefer it though my preference is for Norcuron/Versed and perhaps Fentanyl. The Propofol can have BP issues and maintaining adequate sedation in the transport environment can be risky. Just my preference......
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#14 kdavis308

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Posted 11 June 2011 - 12:18 AM

We do carry it and use it and many of our physicians seem to prefer it though my preference is for Norcuron/Versed and perhaps Fentanyl. The Propofol can have BP issues and maintaining adequate sedation in the transport environment can be risky. Just my preference......


I think you really need to rethink this Norcuron/Versed and perhaps Fentanyl thing making it Fentanyl/Versed and perhaps Norcuron. Having an ET tube stuck in your throat is very painful. Stick your finger in the back out your throat and see if you don't believe me then imagine that 10 times worse. Pain control should be your number one priority, followed by sedation. Paralytics do nothing for the patient other than lead to inadequate use of analgesia and sedation. (Yes, I occasionally use a paralytic outside of initial intubation but it is rare. If they’re flopping, 1 adjust then vent to make sure it is working, 2. give them big doses of analgesics. 3 sedate them 4 repeat analgesia 5 sedate them more 6. analgesia again 7. sedate again. (Get my point).

FYI: there have been a few cases of Propofol infusion syndrome that started within 3 hours.
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#15 old school

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Posted 16 June 2011 - 01:48 PM

Anyone using Propofol in PEDIATRIC transports? If so, do you have particular guidelines you use? Also if anyone has any RECENT research regarding this subject I would appreciate a point in the right direction. Im sure there's lots of data out there & dont want to reinvent the wheel. Any help much appreciated.

Our protocols allow us to use it on anyone over 3 y/o. In actual practice, we normally just continue whatever the sending facility has running, and adjust the dose or add something else as needed.

I personally don't really like propofol in transport, and if I'm choosing I'll usually opt for versed & fent.


I think you really need to rethink this Norcuron/Versed and perhaps Fentanyl thing making it Fentanyl/Versed and perhaps Norcuron. Having an ET tube stuck in your throat is very painful. Stick your finger in the back out your throat and see if you don't believe me then imagine that 10 times worse. Pain control should be your number one priority, followed by sedation. Paralytics do nothing for the patient other than lead to inadequate use of analgesia and sedation. (Yes, I occasionally use a paralytic outside of initial intubation but it is rare.

If they’re flopping, 1 adjust then vent to make sure it is working, 2. give them big doses of analgesics. 3 sedate them 4 repeat analgesia 5 sedate them more 6. analgesia again 7. sedate again. (Get my point).

Well, there are different ways to look at this...

The versed/fent combo is my favorite way to keep a patient comfortable in transport, too. Fent is a great drug to use because it contributes to sedation and allows smaller doses of benzos, and obviously helps mitigate any pain that may be present. Fent kills two birds with one stone and the side effects are minimal, so in that respect, I don't think using fentanyl is ever a bad choice, and relying heavily on fentanyl is usually effective and safe. I know that this is a common approach with peds.

However, I don't know that always assuming that the patient is in a lot of pain is really necessary. Mechanical ventilation - while not particularly comfortable (hence the sedation) - shouldn't in itself be particularly painful, either. I've had many intubated patients over the years who would nod "no" when asked if they were in pain, and I've had many others who couldn't communicate but whose objective signs of discomfort responded better to additional sedation than to additional analgesia. So I like to try to balance sedation vs analgesia depending on the specific needs of the patient, but again, I would agree that at end of the day it is hard to go wrong with fentanyl, since it provides both analgesia and some measure of sedation. Maybe I just do things the hard way.

I don't really agree that "paralytics do nothing for the patient". Of course you do need to be extra vigilant of analgesia & sedation needs when a patient is paralyzed, but it is entirely possible to use both paralysis and adequate sedation, so I view failure to do so as a serious clinical error rather than as an inherent consequence of paralytic use. I use paralytics a lot less now than I used to, but I still use them a fair amount, though much more with adults than with peds.
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#16 jmalia1

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Posted 23 December 2015 - 07:53 PM

We use propofol and we are peds only. The state restricts its use by RNs or medics to only patients that are intubated already so we dont push it for RSI but we use it once they are intubated especially for seizures.


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