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Archive for the ‘ED Guidelines’ Category

Analgesia Policy

From Dr. Hill:

Below is the most important clip from this policy. Starting doses of opiate pain meds are LIMITED BY POLICY. If you give more than the recommended you have to document a rationale. Please adhere to the policy. Analgesia will be tailored for the patient’s pain, see Appendix 2 and 3 of policy below.

  • The recommended initial dose of intravenous morphine in adults is 4 mg (0.05-0.1 mg/kg/dose in pediatrics); up to 10 mg can be given in patients who have chronic pain
  • The recommended initial dose of intravenous hydromorphone is 0.5 mg (0.015mg/kg/dose in pediatrics) up to 1.4 mg in patients who have chronic pain
  • Patients receiving greater than an initial dose of 10 mg of morphine or 1.4 mg of hydromorphone should have a “clinical decision” note entered on the chart and consideration given to contacting the pain service
  • Repeat dosing of morphine or hydromorphone should not be more frequent than every 30 minutes; when given more frequently a “clinical decision” note should be entered on the chart
  • Patients requiring more than three doses of intravenous pain medications in a 3 hour period should be considered for a Pain Service consult

pain-management policy

Written by phil

March 24th, 2010 at 3:47 pm

Sinai Trauma Policy

Goal: To expedite treatment of unstable trauma victims in the ED.

Management:

At the discretion of the ED attending, the admitting surgical resident can be summoned to the ED by page and, if necessary, by overhead, as well as any surgical specialties that may be required.
If there is need for a rapid institutional response, telecommunications/(the page operator) can be notified for a “Trauma Team”. This will not be an overhead page. Rather, telecommunications will then notify the surgical resident on call as well as the Anesthesia, Cardiothoracic surgery on call, Neurosurgery, and Orthopedics.
Any procedures in the ED will be under the supervision of the ED attending. Once the patient is admitted, management may be taken over by the surgical attending if present.
Disposition:
Patients will be admitted by the ED attending to the most appropriate service in consultation with the attending of that service. If the patient has multi-system/service trauma, he/she will be admitted to the General Surgery admitting team for 24 hours if necessary. The patient may then be transferred to the service caring for the most severe injury if all other injuries are stable after 24 hours.

Written by phil

May 7th, 2009 at 5:44 am

Posted in ED Guidelines,Trauma

Diversion Checklist

Written by phil

April 8th, 2009 at 7:22 pm

Wireless Phone Details

Goals:
• Decrease overhead paging/ overhead noise
• Make communication more efficient
• Get out of the phone-answering business
• Trialing all clinical staff will have their own phone

MD Responsibilities:
• Don’t lose the phone
• Use the phone during all clinical shifts
• Make sure the phone is bouncing to the right “ED Zone” (1)
• Click over the patients you take over at sign-out so BAs know who is responsible (2)
• Put your call-back number on radiology requests (3)
• Residents: make sure the BAs know which phone you are carrying
• Residents: phones go in resident office if not in use by EM residents
• Residents: these phones are NOT to go to off service rotators(4)

BA Responsibilities:
• Forward calls to the attending/ resident responsible for the patient (5)
• Ask who is calling before forwarding
• Do not overhead unless the phone is not picking up

1)  Opening screen, go to “ED Zones”, select the appropriate zone-  this selects the phone your no-answer calls bounce to.  Especially important when changing from adult to peds/ east or vise-versa.

2) This is the only way BAs will know which MD is caring for a patient. You can use the sign out function in ibex to change them all over.  You do not need to click on patients with ready beds if transport is imminent.

3) Please enter your callback number on radiology requests- there is a dropdown menu available on request, or you can text.

4) Lost phones are the responsibility of the residency.

5) There is a list of all the wireless phones posted.  The residents will let you know which phone they have at the beginning of the shift.

Written by phil

April 8th, 2009 at 7:18 pm

Policies

The formal, comprehensive repository of our ED policies is here.

For now, on this page, we’ve collected the most relevant policies as well as our frequently used “guidelines” which you may not find on the mssm.edu/emergmed/manual page.

Antibiotic Recommendations
Antibiogram
Capnometry
Central Line Confirmation
Fourth Year Responsibilities
Hemorrhagic Stroke Protocol
Hypothermia Protocol Worksheet Shivering Protocol
ICU Consult (MARS) Criteria
ICU Admission Criteria
Intubation Checklist
OB/GYN Consultation
Pain Policy
Propofol
Sepsis Flowsheet
Stroke Policy
Trauma

Written by phil

February 26th, 2009 at 4:29 pm

Posted in ED Guidelines

Spinal Cord Injury Protocol

We are the spinal injury receiving center for the Jets and the protocol has them coming thru the ED. I have attached a brief synopsis. Talk to Amish or Sigrid about this weekend experience and see Amish on You Tube towards the end of the recording.

Jets Spinal Injury Protocol.

MSH has a new protocol with the jets medical team through Dr Andrew Hecht of orthopedics (spine) to handle all Jets home game player spine injuries. Below is a summary.

On-Field Medical team:
Emergency Physician
Team doctor
Paramedics
Trainer

On Field Capabilities:
RSI Intubation
ACLS
Immobilization
Plain film imaging
Clear spinal injuries will have no imaging before transport

Transport by on-field medical team by ground:
BP control to prevent hypotension
High dose steroids (emcrit)
Hypothermia not part of protocol at this point.

Notification to MSH Upon transport from stadium:
MSH ED: ED Director, A Jagoda, and North attending
Dr. Andrew Hecht of spine ortho or designee
Neurosurgery
Radiology

Arrival at Mount Sinai ED
To be overseen by ED attending on duty
Will be a coordinated multidisciplinary attending driven effort.
There may be public and media attention
Jets PR people will handle all media relations

Written by phil

September 29th, 2008 at 8:33 pm

Posted in ED Guidelines,Trauma

ED EKGs

The south zone attending (the shift formerly known as E.s now ECG.s) needs to sign any unsigned ECGs, located in the red folder under the ECG bin on the specimen desk. There are usually about 10 a day that fall thru the cracks. These need to be signed so the ED can bill for them. You may date the ECG on your date of read, and if, rarely, you find something ominous, check the chart to make sure it was picked up.

Written by phil

September 29th, 2008 at 8:29 pm

Posted in ED Guidelines

ID Approval

You can find the list of meds needing ID approval from the intranet (it took me a while but it’s here). The formal approval process is also described, but summarized below:

From 9-5 if a drug needs approval, page 9407 for adults, 3737 for kids. After hours, fill out the form from IBEX and send it to the inpatient pharmacy, at tube station 39. Drugs that require waking up an ID specialist include amphotericin B, capsofungin, tigecycline, daptomycin, linezolid, and for peds: IV vanc and IV acyclovir.

Written by phil

September 26th, 2008 at 4:04 pm

Posted in ED Guidelines,ID

MICU Admission Criteria

Written by reuben

September 16th, 2008 at 10:30 pm

Posted in ED Guidelines,ICU

OB Policy

This policy outlines the MSSM policy on managing cases that may require obstetrics consultation, including women in their second and third trimesters who present with abdominal pain or bleeding.

Written by reuben

September 16th, 2008 at 10:13 pm

Posted in ED Guidelines,OB/GYN

Pain Policy

Written by reuben

September 16th, 2008 at 10:09 pm

Stroke Protocol

Written by reuben

September 16th, 2008 at 10:04 pm

Trauma Policy

Written by reuben

September 11th, 2008 at 9:20 pm

Posted in ED Guidelines,Trauma

Prevention of Unrecognized Arterial Cannulation

Written by phil

August 17th, 2008 at 12:01 pm

Nighthawks!!

Tuesday, sept 4 2007 the radiology department will begin its contract with Virtual Radiology Partners (a nighthawk type of operation out of Minnosota) to read head and body CTs (not MRIs) from 11:30 pm until 7 am; all of these radiologists are boarded in radiology and licensed in new york. we are promised dictated reads into IBEX within 30 minutes of VRP receiving the films (which will be shortly after the study is completed). radiology residents will not be involved with the reading of films from 11:30 pm until 7 am. questions regarding a read should be directed to VRC by calling 1 (866) 941-5695. VRC does an internal audit for QA on 1% of their charts; our radiologists will do a 100% overread of the VRC reads in the am – it is not anticipated that this will result in missed findings impacting ED decision making.

In order for this to work, please follow these steps:

  1. order in IBEX as usual
  2. call the radiology resident on beeper #1490 so the study can be protocolized(more on this below)*
  3. You must write a reasonable reason why you are getting the study and suspected diagnosis on the request – please do not write “rule out pathology”!!!
    you must include your call back number

Also beginning september 4, 2007, our radiologists will expand their hours of operation with an evening shift. on weekdays there will be a neuroradiology fellow and body fauclty radiologist reading films until 11 pm. on the weekends it will be from 8 am until 5 pm.

*Regarding calling the radiology resident to protocol CTs: up until 11 pm it is optional to let radiology know of an ordered study however it makes sense to facilitate communication as much as possible – especially with sick patients. 79% of radiology requests throughout the hospital come in as “stat” so there is no way the radiologist can know how to prioritize unless you communicate directly. that said, radiology is working to fine tune the process of when the IBEX request is sent and when it is read by the radiologist in order to avoid requests falling between the cracks; the radiology evening supervisors will be inserviced in ensuring ED requests are processed.

After 11 pm – always let the radiologist know of the request . . . if you want the CT done!

Written by phil

August 31st, 2007 at 9:25 pm

Posted in ED Guidelines

Central Line Documentation

We had poor communication in one case that had a central line placed in emergently in the ED but was not documented as such. The ICU did not replace this line and the patient developed an infection within 4 days.

Please document if you did or did not use MAXIMAL STERILE BARRIER precautions in the procedure note and also please communicate this to the accepting service. This is vitally important.

Thanks for your help!

Shkelzen Hoxhaj, MD, MPH

Written by phil

June 20th, 2007 at 5:59 pm

Posted in ED Guidelines

MI Team Activation

7AM- 10PM

To activate the MI Team call the cath lab at 241-5881, tell the clerk that the MI Team is being activated, and ask to speak to an interventional attending to discuss the case. If you can, please document the time you made the call.

10PM- 7AM

To activate the MI Team call AMAC who will then contact the interventional attending on call- this gives you the option of discussing the case/ faxing an EKG to the interventional attending in cases that are borderline. Activation of the remainder of the team will be performed by the interventional attending.

Written by phil

May 17th, 2007 at 6:43 pm

Posted in ED Guidelines

LWBT AMA AND ELOPED PATIENTS

If a patient left before being triaged or put into a bed: Dispo and condition = LWBT. This will probably be diagnosis too. They never made it to a treatment area.

A patient had an AMA discussion and chooses to leave against advice: Dispo and condition= AMA. The Diagnosis is whatever the diagnosis is.

A patient left from the treatment area before completion of treatment, but there was no discharge discussion: Dispo and condition = eloped. Here the diagnosis is as good as you can make it, depending on your contact with the patient.

Eloped should be EVERYONE that made it to the treatment area but left before the discharge decision/ discussion. If they were suitable for d/c but never got papers, you may make dispo discharge, but document they left without papers. If you saw the patient, even from across the room, you should document what you can.

Also- Just to clarify: It is a waste of time to say “remove from board” without putting a Diagnosis/ dispo and condition on the chart.

If someone was sent to L and D, they still need a Diagnosis/ dispo and condition before being removed. This should generally be the senior or north attending job. You may touch base with the charge nurse so she can communicate these to you.

Written by phil

February 8th, 2007 at 4:45 am

Posted in ED Guidelines

Ultrasound Documentation

Bret’s Recommendation is to simply make IBEX Macros of the following:

1. ***ULTRASOUND GUIDANCE FOR VASCULAR ACCESS*** Ultrasound was used to assess potential access sites and guide needle placement for procedure in real time. Electronic images were saved.

[Use this for central venous access and peripheral venous access]

2. ***ULTRASOUND GUIDANCE FOR NEEDLE PLACEMENT*** Ultrasound was used to assess target anatomy and guide needle placement for procedure. Electronic images were saved.

[Use this for: abscess I&D, arthrocentesis, bladder aspiration, lumbar puncture, foreign body removal, or any other procedure]

3. ***ULTRASOUND GUIDANCE FOR PERICARDIOCENTESIS*** Ultrasound was used to assess target anatomy and guide needle placement for procedure. Electronic images were saved.

Written by phil

October 8th, 2006 at 7:26 pm

Posted in ED Guidelines

ED Protocol for Administration of PROPOFOL to Tracheally Intubated Adult Patients

1. Purpose of this Protocol
The purpose of this protocol is to ensure the safe and effective use of PROPOFOL in the ED. This protocol is not intended to replace the full prescribing information but to supplement that information with further details from practical experience. Because of the potential for adverse events and the differences between PROPOFOL and other agents used for sedation, the appropriate use of PROPOFOL in the ED is critical.

PROPOFOL is an intravenous sedative hypnotic agent that is indicated for the induction and maintenance of anesthesia and for sedation during monitored anesthesia care (MAC). It is also indicated for use in the ED as a sedative drug and has proved to be effective for ED sedation in Neuro/Head Trauma patients. It is an appropriate agent for short term sedation (i.e., 6-48 hrs) of ED patients in whom moderate to deep sedation is required followed by relatively rapid wake up time for purposes of assessment of neurological status while awaiting for a bed in the hospital.

2. Clinical Pharmacology
A. Pharmacokinetics
The proper use of PROPOFOL requires an understanding of the disposition and elimination characteristics of PROPOFOL.

The pharmacokinetics of PROPOFOL are well described by a linear three-compartment model with compartments representing the plasma, rapidly equilibrating tissues, and slowly equilibrating tissues. After an IV bolus dose, there is rapid equilibration between the plasma and the highly perfused tissue of the brain. Plasma levels initially decline rapidly because of high metabolic clearance and rapid distribution into the tissues. Distribution accounts for about half of this decline. However, distribution is not constant over time but decreases as body tissues equilibrate with plasma and become saturated.

Discontinuation of the recommended doses of PROPOFOL after the maintenance of anesthesia for approximately one hour, results in a prompt decrease in blood propofol concentrations and rapid patient awakening.

Significant tissue stores of propofol are accumulated after longer infusions (10 day infusion) resulting in a slowed reduction in circulating propofol. As a result, the time to awakening is increased. However, even after long-term administration, rapid awakening within 10 to 15 minutes will occur if the dosage of PROPOFOL is titrated daily to achieve only the minimum effective therapeutic concentration. If higher than necessary infusion levels have been maintained over an extended period, propofol will be redistributed from fat and muscle to the plasma. The return of propofol from peripheral tissues will slow recovery.

The large contribution of distribution (about 50%) to the fall of propofol plasma levels following brief infusions means that after very long infusions (at steady state), about half the initial rate will maintain the same plasma levels. Failure to reduce the infusion rate in patients receiving PROPOFOL for extended periods may result in excessively high blood concentrations of the drug. Titration to clinical response and daily evaluation of sedation levels are especially important during long duration use of PROPOFOL infusion for ED sedation.

B. Pharmacodynamics
The pharmacodynamic properties of PROPOFOL depend on the therapeutic blood concentrations. Steady-state blood concentrations of PROPOFOL generally are proportional to infusion rates, especially within an individual patient.

With longer infusions, the return to the plasma of the drug accumulated in the tissues causes plasma levels to fall more slowly. Thus titration to clinical response of sedation level is important during use of PROPOFOL for ED sedation. Should patients stay in the ED over a 12 hour period, daily evaluation of sedation is important as well.

Undesirable side effects, such as cardiorespiratory depression, are likely to occur at the higher blood levels that result from bolus dosing or rapid increase in the infusion rate. An adequate interval (3 to 5 minutes) between dosage adjustments is necessary to assess the drug’s effects.

3. PROPOFOL differs from other sedative hypnotic agents

The pharmacokinetic and pharmacodynamic properties of PROPOFOL differentiate it from other sedative hypnotic agents. Because PROPOFOL is unlike other sedatives, you must be familiar with the full prescribing information.

PROPOFOL is highly lipophilic. After injection into the bloodstream, PROPOFOL is rapidly cleared from the blood by both distribution into fatty tissues and rapid metabolic clearance via the liver to inactive metabolites.

Although the terminal elimination half-life of PROPOFOL is 1 to 3 days, the rapid metabolic clearance and redistribution into fatty tissues result in a short duration of clinical effect. The sedative effects of PROPOFOL typically dissipate within 5 to 10 minutes after the infusion is discontinued. Thus patients receiving PROPOFOL can be titrated relatively quickly from low levels of sedation to high levels of sedation and vice versa based on clinical need.

With longer infusions, the return to the plasma of the drug accumulated in the tissues causes plasma levels to fall more slowly.

After very long infusions (at steady state), about half the initial infusion rate will maintain the same plasma levels. Thus titration to clinical response and daily evaluation of sedation level are important during use of PROPOFOL infusion for ED sedation, especially of long duration. Excessively high blood concentrations of the drug may result from failure to reduce the infusion rate in patients receiving PROPOFOL for extended periods.

The vehicle (emulsion carrier) for PROPOFOL is essentially Intralipid® 10% (Abbott Laboratories) which also contains 0.005% disodium edetate to retard the rate of growth of microorganisms in the event of accidental extrinsic contamination. However, PROPOFOL is not an antimicrobially preserved product under United States “pharmacopeia (USP) Standards and can still support the growth of microorganisms. Therefore, strict aseptic technique must be adhered to. Aseptic handling methods are discussed on the PROPOFOL label and prescribing information (see below).

The pharmacokinetics of PROPOFOL do not appear to differ with respect to a patient’s sex or the presence of chronic hepatic cirrhosis or chronic renal impairment. The effects of acute hepatic or renal failure have not been studied.

Characteristics of PROPOFOL
Rapid onset of effect because the drug easily crosses the blood-brain barrier (see Clinical pharmacology). Intravenous injection of a therapeutic dose of propofol produces hypnosis rapidly with minimal excitation, usually within 40 seconds from the start of an injection.
Rapid termination of sedation (see Clinical pharmacology).
Resedation has not been seen after the infusion is discontinued if the drug has been carefully titrated.
Can decrease the dose requirements for many other medications, including antihypertensive agents, opioids, muscle relaxants, and lipid supplements.

4. Indications for use of PROPOFOL Injectable Emulsion in the ICU
PROPOFOL is indicated for use only in intubated, mechanically ventilated adult patients. It should be administered only by persons who are skilled in management of critically ill patients and trained in cardiovascular resuscitation and airway management.

PROPOFOL can be used whenever continuous sedation is needed to control anxiety and stress responses. Pain can be treated with relatively small amounts of analgesics. Sedation is achieved independently by titrating the PROPOFOL infusion

PROPOFOL is particularly beneficial in the following clinical situations:
Patients requiring continuous sedation who need to be awakened predictably for either central nervous system (CNS) assessments or weaning from ventilator.
Patients who are agitated and asynchronous with the ventilator.
Patients requiring deep sedation for diagnostic procedures.
Ventilator-dependent patients who require nighttime sedation only in order to maintain an adequate sleep-wake cycle.
Patients with delirium tremens refractory to other GABAergic medications.
Patients fully supported by mechanical ventilation who require short term sedation.
Patients refractory to other sedative agents.

Evaluation of level of sedation and assessment of CNS function should be carried out daily throughout maintenance to determine the minimum dose of PROPOFOL required for sedation.

5. Patients who should NOT receive PROPOFOL Injectable EmulsionPROPOFOL is contraindicated in:
Patients known to be hypersensitive to the drug or its components (soybean oil, egg lecithin, glycerol, and disodium edetate).
Patients in whom sedation is contraindicated.

PROPOFOL is not recommended for use in:
Patients who are not intubated and mechanically ventilated.
Patients who are pregnant or nursing.

PROPOFOL should be used with caution in:
Patients with hyperlipidemia as evidenced by increased serum triglycerides or serum turbidity.
Patients who are hypotensive, hypovolemic, or hemodynamically unstable.
Patients who are predisposed to zinc deficiency, such as those with burns, diarrhea, and/or major sepsis. In these patients, the need for supplemental zinc should be considered during prolonged therapy with PROPOFOL.
In patients at risk for renal impairment, urinalysis and urine sediment should be checked prior to initiation of sedation and then monitored on alternate days during sedation.

6. Practical considerations
This section describes some practical considerations that critical care personnel should note before using PROPOFOL for the first time in ED sedation.

PROPOFOL is not like other drugs used for ED sedation. For example, sedation with midazolam typically is initiated using a bolus injection, followed by either repeat bolus injections or a continuous infusion to maintain sedation. Bolus dosing of PROPOFOL can produce hypotension and cardiorespiratory depression.

It is recommended that sedation with PROPOFOL be initiated with an infusion of 10 mcg/kg/min, and titrated up in 5 to 10 mcg/kg/min increments every 5 to 10 minutes until the desired level of sedation is achieved. Bolus administration should proceed with caution at the time infusion is begun in order to attain an adequate level of sedation within 5-10 minutes because incremental increasing of infusion alone may require 45 – 60 minutes. It is recommended that a bolus of between 0.5-2 mg/kg be given. The PROPOFOL infusion rate for maintaining sedation depends on the individual patient’s condition and age, patient type (e.g., postsurgical or medical), concomitant drug therapy, and the level of sedation desired. Infusion rates of 5 to 100 mcg/kg/min or higher may be required to maintain sedation with PROPOFOL.

PROPOFOL and Analgesic Requirements
Although there are reports of reduced analgesic requirements when PROPOFOL is administered, most patients require opioids for analgesia during maintenance of ED sedation. When using PROPOFOL for ED sedation, you must evaluate the level of pain being experienced by the patient and administer the appropriate amount of analgesic. When pain is adequately controlled, PROPOFOL infusion can be titrated to achieve the desired level of sedation.

Dosages of PROPOFOL should be reduced in patients who have received large doses of opioids. As with other sedative medications, there is interpatient variability in dosage requirements, and these requirements may change with time.
Avoid Waking the Patient Too Quickly.
The wake-up time seen with PROPOFOL is faster than that of other sedative agents.

Because of the rapid clearance of PROPOFOL, abrupt discontinuation of a patient’s infusion may result in rapid awakening of the patient with associated anxiety, agitation, and resistance to mechanical ventilation, making weaning from mechanical ventilation difficult. It is therefore recommended that administration of PROPOFOL be continued in order to maintain a light level of sedation throughout the weaning process until 10 to 15 minutes before extubation, at which time the infusion can be discontinued.

When the PROPOFOL infusion is abruptly discontinued, the plasma levels of the drug decrease rapidly. The wake-up can occur so quickly that the patient may awaken abruptly in pain or to great environmental disorientation. Physicians and nurses may misinterpret the patient’s reaction as agitation caused by the drug. The patient’s reaction, however, is an appropriate response to the sudden influx of stimuli occurring during the transition from deep sedation to rapid, clearheaded awakening.

To avoid the potential problems associated with abrupt awakening, you should not interrupt the PROPOFOL infusion until patient awakening or a change in the level of sedation is deemed necessary.

Two scenarios where this is important are:
The infusion vial of PROPOFOL is inadvertently allowed to run dry (assuming that, as with midazolam or an opioid, the patient is unlikely to move or begin awakening for 30 minutes or more).
A physician or nurse abruptly stops the PROPOFOL infusion to awaken the patient for a physical examination or extubation.

In the first example, the problem can be avoided by ensuring that a second vial of PROPOFOL is immediately available. (The patient may wake up within as little as 5 minutes once the infusion stops, so reinitiating the infusion promptly is critical to ensure uninterrupted sedation.)

In the second example, the problem can be avoided by titrating the infusion rate down so that the patient awakens slowly. A procedure for awakening the patient for an examination or weaning from a ventilator is described below:
Adjust the infusion rate to achieve a light level of sedation.
For patients maintained at a Ramsay score of 3 or higher (see Appendix), decrease the infusion rate in 5- to10-mcg/kg/min increments at 10- to 15-minute intervals until a Ramsay score of 2, or the desired level of light sedation, is achieved.
Once the patient has reached a lightly sedated level, determine the level of orientation that is appropriate for the patient. For example, if the patient can attain full consciousness, gently wake the patient, talk to the patient, and allow the patient to become oriented to the surroundings.
Once the patient is oriented, discontinue the infusion. Within 10 to 15 minutes, the patient usually will be completely awake and clearheaded (assuming that the patient can achieve full consciousness).
After completing the evaluation of sedation level, titrate to a deeper level of sedation (if required) by increasing the infusion rate in 5- to 10-mcg/kg/min increments at 10- to 15-minute intervals.

Titration Is Important
ED sedation should be initiated slowly with a continuous infusion in order to titrate to desired clinical effect and minimize hypotension. Evaluation of level of sedation and assessment of CNS function should be carried out daily throughout maintenance to determine the minimum dose of PROPOFOL required for sedation. The administration of PROPOFOL should be initiated as a continuous infusion and changes in the rate of administration made slowly (>5 minutes) in order to minimize hypotension and acute overdosage.

PROPOFOL facilitates titration because of its pharmacokinetic profile.

Many currently available sedatives are given by bolus injection. If the desired effect is not achieved after 30 minutes or more, the physician or nurse may administer more or less drug the next time. This intermittent bolus procedure often is considered “titrating” the sedative agent.

In contrast, the more rapidly acting vasopressors, such as sodium nitroprusside, are titrated slowly by increasing or decreasing the infusion rate and watching the cardiac monitors for the almost real-time effect. Within minutes, a vasopressor can be titrated to the exact response desired.

You should think of PROPOFOL in the same way as a potent vasopressor:
PROPOFOL should be bolused with extreme caution and careful attention to blood pressure.
PROPOFOL can be titrated within minutes to the desired effect.
PROPOFOL is rapidly cleared by the patient.

Rapid clearance of the drug means that:
The sedative effect can be raised or lowered within minutes with good control.
The patient recovers quickly from effects of PROPOFOL.
The nursing staff must ensure that the vial does not run out.

The speed and convenience of this level of titratability may not be readily apparent unless you understand the pharmacokinetics of PROPOFOL. For example, you need to wait 5 to 10 minutes between dose rate adjustments before the maximal effect is achieved (at which time a further dose adjustment can be made).

7. Initiating sedation with PROPOFOL
To minimize hypotension and avoid acute overdose, you should initiate PROPOFOL slowly using upward titration of a continuous infusion and careful bolus administration.

The dosage of PROPOFOL and rate of infusion must be individualized according to the patient’s condition, age, concomitant CNS drugs (e.g., opioids), blood lipid profile, and vital signs. During the first 24 to 48 hours, the PROPOFOL dosing requirement may gradually increase because of the dissipating effects of previously administered general anesthetics, other sedatives, or opioid analgesics.

DOSING GUIDELINES
Initiate the PROPOFOL infusion at 10cg/kg/min.
Increase the infusion rate in 5- to 10-mcg/kg/min increments every 5 to 10 minutes until the desired level of sedation is achieved.
Wait at least 3-5 minutes between dosage adjustments to allow for onset of maximal sedative and hemodynamic effects.
Monitor patients for early signs of significant hypotension or cardiovascular depression.
Patients with compromised myocardial function, intravascular volume depletion, or abnormally low vascular tone (e.g., sepsis) may be susceptible to hypotension.
Hypotension and cardiovascular depression can be managed by decreasing or discontinuing the PROPOFOL infusion and/or administering IV fluids and/or administering vasopressor therapy.

The initiation dose requirements of PROPOFOL may be reduced in patients with intramuscular or intravenous premedication, particularly with opioids (eg, morphine, meperidine, and fentanyl) and combinations of opioids and sedatives (eg, benzodiazepines, barbiturates, etc). These agents may increase the anesthetic or sedative effects of PROPOFOL and may also result in more pronounced decreases in systolic, diastolic, and mean arterial pressures and cardiac output.

Bolus Dosing
The use of a bolus injection of PROPOFOL is only permitted when performed in a controlled setting and continuous observation of the patient’s state of consciousness and blood pressure is assured. An infusion induction method (upward titration of a continuous infusion) is recommended to minimize hypotension.

8. Maintaining sedation with PROPOFOL
Evaluation of level of sedation and assessment of CNS function should be carried out daily throughout maintenance to determine the minimum dose of PROPOFOL required for sedation.

Maintenance dosages of PROPOFOL must be individualized and titrated to clinical response. The infusion rate depends on the individual patient’s condition and age, patient type (e.g., post-surgical or medical), concomitant drug therapy, and the desired level of sedation.
Most patients can be maintained with 5 to 50 mcg/kg/min or higher of PROPOFOL.
Patients recovering from the effects of general anesthesia or deep sedation and those who have received large doses of opioids may require lower maintenance dosages of PROPOFOL.
Patients in the ED and those who have fully recovered from the residual effects of general anesthesia or previous deep sedation induced by other drugs may require infusions of 50 mcg/kg/min or higher to maintain adequate sedation. These higher rates of administration may increase the likelihood of hypotension.

Patients who require more than 24 hours of continuous PROPOFOL infusion should be awakened daily. This daily evaluation of sedation level should be performed during maintenance to ensure that the patient is receiving the minimum dose of PROPOFOL required for sedation.

During maintenance infusion, you should monitor the patient’s vital signs, including blood pressure, heart rate, and if available, cardiac output and pulmonary capillary wedge pressure. If mild hypotension develops during titration, decrease the infusion rate of PROPOFOL. If clinically significant hypotension or cardiovascular depression occurs, discontinue vasodilator therapy (if applicable), administer intravenous fluids or vasopressor therapy, and discontinue the PROPOFOL infusion.

Once the patient has achieved an adequate level of sedation and is hemodynamically stable, you can maintain that rate of PROPOFOL infusion, except when titration is required for wake-up physical or neurologic assessment, family visits, or nursing care. You can sedate the patient more deeply during the evening hours or when the patient undergoes unpleasant procedures.

Determining the Minimum Maintenance Dose
Patients receiving maintenance infusions of PROPOFOL should be awakened daily to assess their respiratory and neurologic functions. These evaluations of sedation level are needed to ensure that the patient receives the lowest effective dose of PROPOFOL and that the patient’s pain is adequately managed.

Evaluation of level of sedation and assessment of CNS functions should be carried out daily throughout the maintenance to determine the minimum dose of PROPOFOL required for sedation.

9. Discontinuing or modifying the rate of infusion with PROPOFOL Injectable EmulsionThe PROPOFOL infusion should be discontinued or the rate of administration reduced:
If significant hypotension develops.
If unacceptably high triglyceride levels develop.
When sedation is no longer needed.
When the daily evaluation of sedation level is performed.
When the patient is extubated.

Because of the rapid clearance of PROPOFOL, abrupt discontinuation of a patient’s infusion may result in rapid awakening of the patient with associated anxiety, agitation, and resistance to mechanical ventilation, making weaning from mechanical ventilation difficult. It is therefore recommended that administration of PROPOFOL be continued in order to maintain a light level of sedation throughout the weaning process until 10 to 15 minutes before extubation, at which time the infusion can be discontinued.
Weaning from the Ventilator
The following procedure should be used when a patient who is sedated with PROPOFOL is weaned from a ventilator:
Discontinue concomitants, opioids, and paralytic agents (if applicable).
Gradually decrease the PROPOFOL infusion rate until the patient reaches a light level of sedation.
After the patient has been fully weaned from mechanical ventilation and meets all other extubation criteria, discontinue the PROPOFOL infusion 10 to 15 minutes before extubation.

10. Handling and administration

PROPOFOL Injectable Emulsion is a single-use, parenteral product that is formulated in a white, oil-in-water emulsion. The formulation also contains soybean oil (100 mg/mL), glycerol (22.5 mg/mL), egg lecithin (12 mg/mL), and disodium edetate (0.005%). The PROPOFOL vehicle is essentially Intralipid® 10%. Therefore, many of the handling, drug compatibility precautions, and administration line procedures used for Intralipid are applicable to PROPOFOL.

Strict aseptic technique must always be maintained during handling. PROPOFOL is a single-use parenteral product which contains 0.005% disodium edetate to retard the rate of growth of microorganisms in the event of accidental extrinsic contamination. However, PROPOFOL can still support the growth of microorganisms, as it is not an antimicrobially preserved product under USP Standards. Accordingly, strict aseptic technique must still be adhered to. Do not use if contamination is suspected. Discard unused portions as directed within the required time limits. There have been reports in which failure to use aseptic technique when handling PROPOFOL was associated with microbial contamination of the product and with fever, infection/sepsis, other life-threatening illness, and/or death.

When PROPOFOL is administered directly from the vial, strict aseptic techniques must be followed. The vial rubber stopper should be disinfected using 70% isopropyl alcohol. A sterile vent spike and sterile tubing must be used for administration. As with other lipid emulsions, the number of IV line manipulations should be minimized. Administration should begin promptly and must be completed within 12 hours after the vial has been spiked. The tubing and any unused portions of the PROPOFOL must be discarded after 12 hours.

If PROPOFOL is transferred to a syringe, or other container before administration, or if a PROPOFOL prefilled syringe is used, the syringe(s) or container(s) should be labeled with the date and time the PROPOFOL container was opened. Administration should begin promptly and be completed within 6 hours. The PROPOFOL should be discarded and the administration lines changed after 6 hours.

Rare cases of self-administration of PROPOFOL by health care professionals have been reported, including some fatalities. PROPOFOL should be managed to prevent the risk of diversion, including restriction of access and accounting procedures as appropriate to the clinical setting.
Summary of Handling Procedures for PROPOFOL
Use aseptic technique
Strict aseptic techniques must be followed when handling PROPOFOL. It is not an anti-microbially preserved product under USP Standards.
The vial rubber stopper should be disinfected using 70% isopropyl alcohol, and a sterile vent spike and sterile tubing must be used for administration.
As with other lipid emulsions, the number of IV line manipulations should be minimized. Administration should commence promptly and must be completed within 12 hours after the vial has been spiked for direct administration. The tubing and any unused portion of PROPOFOL must be discarded after 12 hours.
If PROPOFOL is transferred to a syringe or other container before administration, the handling procedures for General Anesthesia/MAC Sedation should be followed, and the product should be discarded and administration lines changed after 6 hours.
Inspect the drug for particulate matter and/or discoloration before administration.
Do not use if there is emulsion separation.
PROPOFOL should not be administered through a filter with a pore size of [less equal]5 microns, unless it has been demonstrated that the filter does not restrict the flow of PROPOFOL and/or cause the breakdown of the emulsion. Filters should be used with caution and only where clinically appropriate. Continuous monitoring is necessary due to the potential for restricted flow and/or breakdown of the emulsion.
Administration Procedures
You can administer PROPOFOL through a central line or a peripheral infusion line. Two procedures are available for administering PROPOFOL.

Direct infusion: The 50-mL or 100-mL infusion vials (which contain 10 mg/mL of PROPOFOL) can be used for direct infusion. A sterile vent spike and sterile tubing must be used. IV line manipulations should be minimized. Administration should begin promptly and must be completed within 12 hours after the vial has been spiked. The tubing and any unused portions of the drug must be discarded after 12 hours.

Transfer before infusion: If you transfer PROPOFOL to a sterile syringe or other container, or use a prefilled syringe, label the syringe or container with the date and time. The syringe or container and the tubing should be replaced every 6 hours.
Use of Infusion Devices
You can administer PROPOFOL using a volumetric or syringe pump. The type of device is less important than ensuring that the nursing staff is familiar with the equipment.

11. Compatibility
Dilution Prior to Administration:
PROPOFOL® (propofol) Injectable Emulsion is provided as a ready-to-use formulation. However, should dilution be necessary when PROPOFOL is diluted prior to administration, it should only be diluted with 5% Dextrose Injection, USP, and it should not be diluted to a concentration less than 2 mg/mL, because it is an emulsion. In diluted form it has been shown to be more stable when in contact with glass than with plastic (95% potency after 2 hours of running infusion in plastic).

Administration with Other Fluids:
Compatibility of PROPOFOL with the coadministration of blood/serum/plasma has not been established. PROPOFOL has been shown to be compatible when administered with the following intravenous fluids.
5% Dextrose Injection, USP
Lactated Ringers Injection, USP
Lactated Ringers and 5% Dextrose Injection
5% Dextrose and 0.45% Sodium Chloride, USP
5% Dextrose and 0.2% Sodium Chloride, USP
Drug Interactions
PROPOFOL dose requirements may be reduced in patients receiving concomitant opioids or a combination of opioids and sedatives. These agents may increase the sedative effects of PROPOFOL and may also result in more pronounced decreases in blood pressure or cardiac output.

Patients with compromised myocardial function, intravascular volume depletion, or abnormally low vascular tone (e.g., sepsis) may be more susceptible to hypotension. Patients should be monitored for early signs of significant hypotension and/or cardiovascular depression, which may be profound.

12. Adverse events
Like other potent drugs, PROPOFOL has been associated with adverse events.

Hypotension was causally related in 26% of patients receiving bolus doses of PROPOFOL for ED sedation. In most cases, the decrease in blood pressure responded to fluid or vasopressor administration and/or adjustment or discontinuation of PROPOFOL.

Other causally related adverse events include hyperlipidemia, decreased cardiac output, bradycardia, and respiratory acidosis during weaning from a ventilator. Adverse events occurring rarely but probably casually related were green urine, agitation, and decreased lung function.

Because PROPOFOL is an oil-in-water emulsion, it should be used with caution in patients with lipid metabolism disorders, such as primary hyperlipoproteinemia, diabetic hyperlipemia, and pancreatitis. Elevations in serum triglycerides can occur when PROPOFOL is administered for extended periods. Patients at risk for hyperlipidemia should be monitored for increases in serum triglycerides or serum turbidity.

Studies to date, in patients with normal or impaired renal function have not shown any alteration in renal function with PROPOFOL. However, in patients at risk for renal impairment, urinalysis and urine sediment should be checked before initiation of sedation and then monitored on alternate days during sedation.

Overdosage
If overdosage occurs, you should immediately discontinue the PROPOFOL infusion. Overdosage can be avoided by slowly titrating the infusion.

Extravasation
As with any IV drug, extravasation into surrounding tissues has occurred with PROPOFOL. However, extravasation has not been associated with tissue necrosis. It can be managed with local care, such as elevation of the affected site to reduce swelling. PROPOFOL rarely causes phlebitis.

Appendix. Determining the level of sedation
Evaluation of level of sedation and assessment of CNS function should be carried out daily throughout maintenance to determine the minimum dose of PROPOFOL required for sedation.

Determining the appropriate level of sedation can be facilitated through the use of sedation scales. Sedation scales can improve patient care by improving communication among ICU personnel. Staff members can refer to specifically defined levels of sedation when discussing their patients.
Various types of sedation scales exist. The best sedation scale is one that is convenient to use and is used consistently by all members of the department. In the absence of a preestablished sedation scale, you may consider using the Ramsay scale or a modified Ramsay scale:
Ramsay Scale
Patient anxious and agitated, or restless, or both.
Patient cooperative, accepting ventilation, oriented, and tranquil.
Patient asleep; brisk response to light glabellar tap or loud auditory stimulus.
Patient asleep; sluggish response to light glabellar tap or loud auditory stimulus.
Patient has no response to light glabellar tap or loud auditory stimulus but does respond to painful stimulus.
Patient does not respond to painful stimulus.
Modified Ramsay Scale
Patient anxious, agitated, or restless.
Patient cooperative, oriented, and tranquil.
Patient responds to commands only.
Patient responds to gentle shaking.
Patient responds to noxious stimulus.
Patient has no response to firm nailbed pressure or other noxious stimuli.

Appendix II. Lipid profile of PROPOFOL Injectable Emulsion
The PROPOFOL contains soybean oil (100 mg/mL), glycerol (22.5 mg/mL), and egg lecithin (12 mg/mL). One milliliter of PROPOFOL contains approximately 0.1 g of fat (1.1 kcal). Other sources of dietary intake, particularly Intralipid®, must be adjusted to compensate for the amount of lipid infused during PROPOFOL administration.

You should note on the patient’s chart the kcal equivalent of PROPOFOL being administered and ensure that the patient’s lipid nutritional supplement (eg, Intralipid) is reduced by an equivalent amount if the PROPOFOL infusion is likely to be continued for more than 24 hours..
Because PROPOFOL is an oil-in-water emulsion, it should be used with caution in patients with lipid metabolism disorders, such as primary hyperlipoproteinemia, diabetic hyperlipemia, and pancreatitis. Elevations in serum triglycerides can occur when PROPOFOL is administered for extended periods. Patients at risk for hyperlipidemia should be monitored for increases in serum triglycerides or serum turbidity.

Written by phil

July 12th, 2006 at 4:47 pm

Posted in ED Guidelines

Sepsis Protocol

Written by phil

May 25th, 2006 at 5:30 pm

Posted in ED Guidelines,Sepsis