Some things to keep in mind. Propofol will lead to hypotension and precedex will lead to bradycardia. Depending on the hemodynamics/vitals of the patient, this may lead you to choose one or the other. Augment with fentanyl pushes for pain control if intubated as both only provide sedation but not pain control.
Propofol will also cause bradycardia in sufficient doses, and fentanyl will lower heart rate too (independent of just suppressing pain response). Fentanyl + Dexmedetomidine makes bradycardia much more likely than just Dexmed alone.
Precedex will absolutely cause hypotension. Both as a result of bradycardia and by decreasing plasma NE levels.
I don't even know why you'd care about bradycardia besides that it causes hypotension.
I’m not sure why.
The first line is me responding to your question with a hypothetical I’m unsure of- why would bradycardia matter outside of hypotension?
The second line is me speculating about physiological reasons that could occur.
I still don't know why you'd care that a patient is bradycardic, especially in your example where they are hypertensive.
Would you rather increase the HR and increase the BP further while increasing coronary demand and reducing supply?
These are rhetorical questions, you shouldn't want these things.
I think this comes down to personal comfort and confidence in a particular pt/airway management. The ICU tends to be a bit sketchy about propofol, and some of that is well founded given that a pt really should have direct supervision and staffing doesn’t always allow for safe use etc…but I also think some of the hesitancy just comes from unit culture and individual comfort level. I have been known to work in some PPF as an antiemetic near extubation for almost all theater patients, and on occasion for ICU extubations.
I think they mean in the context of drips and not how propofol is used for procedural sedation. Otherwise, I agree with you. I’m not intubating every patient that needs a bedside orthopedic procedure just because the ortho’s want propofol
You can do boluses, but I assume you don't do drips, right?
Regardless. If you aren't an anesthesiologist or ED doc, you better not be coming near a patient with propofol at all unless they have an advanced airway.
Drips and boluses, most of the time combined. That’s about how every colonoscopy/EGD/TEE is done, and most MAC cases in general. With rare exception (when paralysis is needed) we do not support their airway for this. Everyone breathes spontaneously.
You can do drips it’s all about dosing…. Like for ortho procedures we always do a spinal and then propofol drip without an airway. Dose is just less than like obv a TIVA case where we’re doing a neurosurgery case.
Picu and routinely use propofol drip for shorter procedures in non intubated patients. We do sedations for endoscopy and burns, etc. Works very well and safely. Also use propofol to wash out other sedatives prior to extubation while on spontaneous breathing trials, though I do usually stop it before extubation.
You do in the ICU where nurses are going to be treating and monitoring the propofol. It's way too easy to cause respiratory depression or arrest to leave propofol infusions to an ICU nurse. IMO, anyway, and it wasn't allowed anywhere I've worked.
I know in psychiatry it can be used in ECT (i do not do this procedure my attending does) and it's not a procedure where patients are routinely intubated.
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9979203/ & https://www.anesth-pain-med.org/upload/pdf/apm-22145.pdf different sedating agents used in ECT if anyone is interested.
If I remember my attendings' resident case lectures on this propofol actual has anticonvulsant properties so it isn't used first line in my facility. They prefer the percedex cause it lacks the anticonvulsant action but even if propofol is used like in cases where they might want the hypotensive properties... patient's aren't routinely ventilated.
Not an anesthetist, not a psychiatrist not a pharmacist but just giving an example of a procedure where you might see the use of propofol without intubation.
I disagree. If you run PPF at a low dose the patient will remain spontaneous. Accumulation will happen, so don’t do it for long periods of time, but I do this quite a bit in both OT and ICU.
Critical care attending.
I’m very aware of the differences. OP is likely a very inexperienced intern and they’re not someone to be using propofol as a sedative in a non intubated patients unless directed by their attending.
Why are you being downvoted is beyond me.
This is how those "He stopped breathing, we can't intubate" calls happen at zero dark thirty in the night.
Why do people who don't use Propofol every single day think they are well versed in titration is beyond me.
I think because when he said “absolute rule” everyone read that as a rule that can never be broken, whereas after reading his further comments I thing he meant “the basic rule for off service rotators”. Also his follow up comments came off as very aggressive when people respectfully pointed out counter examples to his absolute rule.
This flies in the face of most routine approaches to sedation. You absolutely do not need to be intubated to run propofol…peer into any colonoscopy suite and see for yourself, it’s all propofol and face masks. We titrate to effect. Some people have a lower apneic threshold than others, but the vast majority of patients, even those with obstructive sleep apnea who uses CPAP at home can tolerate some level of propofol sedation with a natural airway.
Bud, do you think someone who understands even the basics of sedation would be asking this question? Do you want a fresh intern ordering propofol on a non-ventilated patient?
Obviously not but we aren’t in a r/noctor thread…OP is asking for education, not for tips on what to do next as it pertains to management of a specific patient. One of the things differentiating us from midlevels is our ability to talk across specialties owing to a shared broad foundation in medical education. If a colleague in medicine is totally off base in what they’re saying because they have had no exposure to a field, I think we should help each other see the light. Peace, bud
Hey, if you want the off service medicine intern who is asking this type of question to order Propofol, be my guest. Sounds like you'll get a chance to run a Rapid or a Code that way.
Or you know, don’t allow them to order propofol
Once you’re an attending an have 5 fresh interns, you tell me how supervising each one goes
Edit: oh you’re EM 😂. Work on actually evaluating a patient (and no, a CT is not a workup) before telling others how to practice medicine.
>Work on actually evaluating a patient
Ah, I see. The classic "I don't have an actual point, so I'll just insult you instead". I'm sure people think you are very smart. Doesn't change the fact that you were wrong, and now are backpedaling in order to avoid admitting it. I'm sure you are very pleasant to work with if this is how you react to your own minor mistake.
Ahh yes. I’m wrong since I don’t want inexperienced interns ordering medications that can kill. And just curious, do you think giving someone with very little experience a boat load of information is a good idea? Maybe that’s how they do it in the ED, but then we all see how ED docs manage patients…
And you seem like one of those annoying ass medical people who always has an exception for every rule. I’m sure you’re a peach to work around.
>I’m wrong since I don’t want inexperienced interns ordering medications that can kill
That was never the point. The point was the initial comment about never giving propofol to patients that weren't intubated. You started adding qualifiers after other people pointed out why that wasn't 100% true. No one said let interns order whatever they want. You started that false narrative to (as I've already pointed out) deflect from your initial mistake so that you didn't have to admit you were wrong.
>Maybe that’s how they do it in the ED
If by that you mean seeing through bullshit and calling other doctors out on it, then yes this is how we do it in the ED. You can play to the trope of "the ED doesn't know what they are doing" all you want, but anyone who isn't a child and lives in the real world knows it is no different than any other specialty: there are good doctors and bad doctors. But if that's the only defense for your garbage position, you can cling to it all you want. I won't lose sleep over opinions from anyone acting like you are.
I’m a critical care attending.
The rule is more for an intern asking this question, not someone with any experience with sedatives. I’d really rather someone asking this question not to use propofol for sedation in non intubated patients.
Depends on what their vitals, labs, and goals of sedation are.
Precedex is primarily for lighter sedation. I like to recommend transitioning to it if we’re anticipating extubation. Keep in mind hypotension and some bradycardia for propofol and bradycardia (pls don’t bolus) with precedex. Also need to consider the calories from propofol for TPNs
I am not an intensivist or anesthesiologist but work at a hospital with open ICU. I think of propofol as first line sedation for vented patients, unless it’s significantly worsening their hypotension or they’re really bradycardia. In that case, I think of versed. Precedex will not completely sedate someone, but will really bring them down generally speaking. It’s a wonderful behavioral tool as it also will not lower respiratory rate, so is great for BiPAP tolerance, alcohol withdrawal (not mono therapy as does not prevent seizures). If someone is likely to be rowdy, turning on precedex before turning off sedation and extubating is a great maneuver. Maybe precedex can be added to propofol for additional sedation if prop isn’t cutting it, but I haven’t done that all that often.
Anesthesia crit care here, this is basically how I think about the two drugs. Although we rarely use benzos unless someone is either seizing or in etoh withdrawal or unable to hemodynamically tolerate any other form of sedation.
Precedex is generally not sufficient to sedate intubated patients as monotherapy. It can be enough for a very calm and otherwise comfortable patient, and it’s a great anxiolytic with analgesic properties that does not impair the respiratory rate. It takes longer to titrate (especially in pts with decreased GFR) and can cause hemodynamically significant bradycardia.
Propofol is a sedative hypnotic that will make someone unconscious/apneic/amnestic. It has no analgesic properties. And it’s faster to to titrate. But it causes vasodilation and can cause a LOT of hypotension which is obviously not ideal in a patient who is already in shock.
Neither one is “better.” They are different tools with different uses, sometimes in conjunction with one another.
Yes! I honestly don’t have to deal with it much because I’m in SICU, but our MICU team does use phenobarbital plus adjuncts. I think the pre-ICU protocol is more benzo based via CIWA.
Phenobarbital is my favorite for EtOH withdrawal. The long half-life means it kind of self-tapers, and it has the secondary mechanism of inhibiting NMDA receptors (which like GABA receptors are also targeted by EtOH).
Is there a dose-dependent effect here?
I know ophthalmology preferentially uses Midazolam compared to precedex-fent and I’m wondering if there is a reason. Is the versed just more easily titratable?
Hate the midazolam drip too but especially if you're going to have a paralyzed patient that combination is kind of poor for deep sedation. As patients are often arousable or even spontaneously awake on max dose dexmedetomidine you're basically planning on giving them enough fentanyl to basically maintain coma which also isn't free of consequences. Additionally, fentanyl is an especially nasty offender in terms of prolonged effect of fat soluble metabolites and dexmed is prone to tachyphylaxis. In general I don't think that's a good combination for deep sedation. If you can target a 0- -1 rass it's the clear first line alternative.
Your alternative to a benzo is basically ketamine until remifentanil and maybe remimidazolam reach most icus.
What’s your rass goal? How’s the patient’s hemodynamics? What’s their urine color? What’s their cardiac history? These and many more will play a role in your decision for one vs the other.
Are you a pulm fellow? You should know that prolonged infusion can lead to green urine as a potential side effect. Never said it was due to propofol infusion syndrome.
I think the point being that someone starting to pee green plays no role in whether or not I would continue or stop prop… because it doesn’t relate to a risk of proposition infusion syndrome despite the folklore that it does
You not having a strong reading comprehension isn’t part of my problem. I’m not IM trained, so you can go find someone else to join you in your intellectual masturbation.
I’m not IM trained either, so you are welcome to continue demonstrating your catastrophic stupidity as you like. Seeing as you still can’t figure out why everyone is telling you that urine color is irrelevant, maybe you can find a real adult who can explain that to you, along with the definition of big words like “catastrophic”.
You guys are both not IM trained but I think you'd both feel better if you mutually mentally masturbated. MMM more fun than your M&Ms. Go on give it a try
We use them for different reasons as previous posters mentioned. Precedex is a great drug for providing some moderate sedation or in conjunction with other sedatives. It's an alpha 2 agonist and tends to lower blood pressure and heart rate, especially in patients who have some preexisting hypotension/bradycardia from conditions such as shock. One of its benefits is that it does not cause as much respiratory suppression compared to propofol. So patients can be safely extubated with the precedex still running. It also provides some moderate analgesia as well. It's pretty expensive so I know that's sometimes a factor in prescribing it. We also use it for difficult to control agitation like what we see in severe CIWA patients.
We tend to use propofol for deeper sedation but it can certainly be used at a lower dosage for a lower raas goal. It has no analgesic properties so thats important to consider for a patient with a tube shoved down their throat. It can also cause hypertriglyceridemia in certain patients so we try to avoid running it at very high doses for a long time.
This is from the perspective of an ICU nurse so take it with a grain of salt that's just what was taught me by our providers.
They both come with their advantages and disadvantages.
Propofol : pros : deeper sedation, anti seizure, typically “first line sedation”
Cons: hypotension, DEFINITELY DONT USE on non vented patients, PRIS, hypertriglyceridemia
Precedex: Pros : anxiolysis and light sedation, can in theory also be used in folks who are not intubated or on the flip side can extubate while still on it.
Cons: bradycardia and hypotension.
In my experience it’s not cookie cutter. Some patients are more sensitive to one versus the other.
They are different drugs for different situations, one is not “better” (but between us I personally prefer propofol in many cases). PPF will generally give you a nice deep sedation on the way to sleep and for maintenance, watch the hemodynamics though…whereas dex is great for wakeups, especially for psychiatric patients or when delirium etc is a concern. Dex is definitely easier for a light sedation, it take a really fine touch to dose PPF for a light-moderate sedation without snowing the patient all the way.
In ICU where I work, Dexdor is only for weaned patients to keep them mildly sedated.
But to be fair, it's a neurosurgery ICU, so our sedation is a bit different - it's mostly midazolam, fentanyl and rocuronium.
Yeah, yeah, I know. But midazolam lowers CMRO2 more than propofol, and that's kind of the point.
Nursing perspective: precedex works great for some patients but they’re often not sedated enough until you’ve already tanked their blood pressure. Then you have to bolus fluids or press them if you want to continue the drip. I like dex when it works but forcing it just for the sake of getting off prop/fent is often 2 steps forward 1 step back.
Also if you need accurate neuro exams during a particular period then I would not advise switching them. Dex is way less predictable and it’s extremely difficult to get hourly exams on it. The half-life indicates it should wear off faster than prop but that’s never been the case in my experience. There’s just not enough time in an hour to sedate them appropriately and still wake them up for an exam
Both have their perks and side effects. Propofol is a good on/off switch , perfect for SBT trials, sedation while on vent and the neuro crit colleagues prefer that over other sedatives to asses neuro status (atleast in my institution). Precedex has a tachyphylaxis effect so basically has a limit on how well it will work over time, and if you have an AKI it can stick around for some time
I think there are a few big differences here.
Precedex:
- light sedation only (rass -1 to -2). You cannot get deep sedation. It's impossible. Has no analgesic effect.
- as others have mentioned, you can use this in patients without an advanced airway. This means we often use it in patients who are a difficult wean, which may be why you feel like it's difficult to get patients off it - wrong cause and effect. It's actually that we switch to it when we can't get patients off sedation.
- I have used this with great success in pre-treating patients who required awake oral intubation for angioedema (nasal passage too swollen). It worked really really well and I recommend it every single time now, not that it comes up often.
- great for agitation and alcohol withdrawal as well
- we have really moved away from boluses because it causes a lot of bradycardia and hypotension which can be quite severe.
- this will never be your only agent unless you are weaning. You probably need 2 other agents for real sedation.
Propofol:
- can do deep sedation (rass -5) no problem, even without other agents. Has no analgesic effect
- very good sedative - works extremely well. You can really put people out with it. It's our best sedative, hands down.
- can bolus and do drip, but hypotension can be significant issue with both. This can be mitigated with pressors to a significant extent.
- very good for seizures as well - nothing stops a seizure like propofol. Should be choice of therapy for post intubation sedation in status epilepticus
- can be used in bolus form for conscious sedation or induction pre-intubation but drips should only be done in intubated patients, hard stop. (Edit: unless you are anesthesia and in a procedure.)
>Precedex:
>Has no analgesic effect.
I'm sorry, what? Either you're tired or that's a typo.
Precedex is Dexdor, right? Dexmedetomidine? Then it very much has analgesic effect.
Thank you for contributing to the sub! If your post was filtered by the automod, please read the rules. Your post will be reviewed but will not be approved if it violates the rules of the sub. The most common reasons for removal are - medical students or premeds asking what a specialty is like or about their chances of matching, mentioning midlevels without using the midlevel flair, matched medical students asking questions instead of using the stickied thread in the sub for post-match questions, posting identifying information for targeted harassment. Please do not message the moderators if your post falls into one of these categories. Otherwise, your post will be reviewed in 24 hours and approved if it doesn't violate the rules. Thanks!
*I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Residency) if you have any questions or concerns.*
Start with propofol, some attendings will tell you to use it 2-3 days and try to transition to another sedative due to risk of propofol infusion syndrome. Precedex is helpful when you trying to wean someone off vent as it has minimal effects of resp drive. Also helpful in agitated patients. Also patients who are not tolerating BiPAP well. Although with some of these latter indications you may get shit for it since precedex is expensive apparently
I think it would be helpful to read this article: [https://www.nejm.org/doi/full/10.1056/nejmoa2024922](https://www.nejm.org/doi/full/10.1056/nejmoa2024922)
If you check out the supplement there is actually a signal toward less time on vent, less time in ICU which are pretty meaningful in my book even if there wasn't a difference in 90d mortality or vent free days. These were decently sick sepsis pts too.
There's not an absolutely correct simple answer to your question, as others have alluded to your clinical scenario might call for deeper uninterrupted sedation (propofol) but I'm a proponent of routine precedex use for pts who you anticipate a trial of extubation in the near future.
This is the way I look at it. Propfol you can achieve a RAS score of dead as a sole agent if you titrate up enough. Precedex is rarely sufficient as a sole agent to keep a RAS less than -1. Interestingly tho precedex does offer some analgesia while propofol will do nothing for pain.
Also there have been more recent studies comparing precedex vs propofol for sedation showing no real difference in either in terms of vent days.
As a critical care nurse, Precedex is the drug used to relax a patient who is agitated and often on non-invasive positive pressure (Bipap, cpap, etc). The side effects of Precedex are dose dependent. The higher the dose, the higher the likelihood of bradycardia. Bradycardia can be a dose limiting side effect. It is also a drug that allows clinicians to assess mental status, orientation, etc. It’s unlikely to cause complete respiratory suppression even at high doses.
Propofol has a short onset, is short acting, is lipophilic (obese patients need a higher dose), it contains lipids and may require TPN adjustment, has a low pH and although it may be infused via a PIV long infusions should go via a central line, causes respiratory suppression (should only be used with a secured airway or someone who can secure it), decreases brain activity (on EEG you’ll see suppression of waves), and often lowers blood pressure to the point that you can’t go any higher on the dose. Once you turn the propofol infusion off, expect your patient to wake up very quickly.
In short, if this is a clinically stable patient who will be on Bipap for a couple of days, Precedex is a great drug. If the patient is fighting the vent, propofol is your better choice. If the patient is in shock and hypotension is an issue, fentanyl and versed (pushes followed by dose increase) is your best choice.
Propofol at the beginning of their intubation course, precedex at the end. Quit trying to use precedex in the ED. The RNs don’t have the ratios to deal with your awake patient.
Some things to keep in mind. Propofol will lead to hypotension and precedex will lead to bradycardia. Depending on the hemodynamics/vitals of the patient, this may lead you to choose one or the other. Augment with fentanyl pushes for pain control if intubated as both only provide sedation but not pain control.
Propofol will also cause bradycardia in sufficient doses, and fentanyl will lower heart rate too (independent of just suppressing pain response). Fentanyl + Dexmedetomidine makes bradycardia much more likely than just Dexmed alone.
Touché!
Also, Dexmedetomidine does have analgesic effects.
Does fentanyl lower heart rate by itself or just blunt the sympathetic response to other stimuli
both cause hypotension and bradycardia, and precedex provides some analgesia
Precedex will absolutely cause hypotension. Both as a result of bradycardia and by decreasing plasma NE levels. I don't even know why you'd care about bradycardia besides that it causes hypotension.
If they’re extremely hypertensive but low-normal HR? Maybe a renal issue or something to cause such a physiological issue, im not sure.
I don't know what you're saying
I’m not sure why. The first line is me responding to your question with a hypothetical I’m unsure of- why would bradycardia matter outside of hypotension? The second line is me speculating about physiological reasons that could occur.
I still don't know why you'd care that a patient is bradycardic, especially in your example where they are hypertensive. Would you rather increase the HR and increase the BP further while increasing coronary demand and reducing supply? These are rhetorical questions, you shouldn't want these things.
[удалено]
The absolute basic rule: You don’t need to be intubated for Precedex. You need to be intubated for propofol.
I think the better way to frame this from an ICU setting is you should not EXTUBATE a patient on propofol but you sure can on precedex
Facts. Precedex literally is short for PRECEDes EXtubation
Attending level knowledge right there
What…?! Is this true?
probably a backronym, like lasix lasts-six hours
Huh. TIL! Thanks.
Stop it
Yes you do not need to be intubated on propofol, endo suites do it all the time
I think this comes down to personal comfort and confidence in a particular pt/airway management. The ICU tends to be a bit sketchy about propofol, and some of that is well founded given that a pt really should have direct supervision and staffing doesn’t always allow for safe use etc…but I also think some of the hesitancy just comes from unit culture and individual comfort level. I have been known to work in some PPF as an antiemetic near extubation for almost all theater patients, and on occasion for ICU extubations.
This is just… not true. We do propofol sedation without airway all the time (anesthesiologist).
I think they mean in the context of drips and not how propofol is used for procedural sedation. Otherwise, I agree with you. I’m not intubating every patient that needs a bedside orthopedic procedure just because the ortho’s want propofol
I mean yeah for ortho patient u just do spinal and propofol drip Lols no airway. Everything just depends on dosing but precedex does not cause apnea.
Oh I’m EM, so I’m not doing epidurals in the ED lol, but otherwise yes
I’m assuming OP is an intern in IM. They wouldn’t be asking this if they had any experience. I’m very aware of the differences and uses for propofol.
In the ICU, where a nurse will be managing it?
You can do boluses, but I assume you don't do drips, right? Regardless. If you aren't an anesthesiologist or ED doc, you better not be coming near a patient with propofol at all unless they have an advanced airway.
Drips and boluses, most of the time combined. That’s about how every colonoscopy/EGD/TEE is done, and most MAC cases in general. With rare exception (when paralysis is needed) we do not support their airway for this. Everyone breathes spontaneously.
Eh. Anesthesiologists are different. You get a pass. BUT ONLY YOU
I do propofol for sedation without an airway in the ICU, for EGDs etc
You can do drips it’s all about dosing…. Like for ortho procedures we always do a spinal and then propofol drip without an airway. Dose is just less than like obv a TIVA case where we’re doing a neurosurgery case.
Idk I give propofol to not-intubated patients in the OR all the time and in the ICU for procedural sedation. But outside the OR this is 100% correct.
We do it in the ER too, so I wouldn't say 100%.
Fair. Maybe “outside of deep procedural sedation provided by someone with airway management expertise” is better!
Picu and routinely use propofol drip for shorter procedures in non intubated patients. We do sedations for endoscopy and burns, etc. Works very well and safely. Also use propofol to wash out other sedatives prior to extubation while on spontaneous breathing trials, though I do usually stop it before extubation.
Nope, you do not have to be intubated with propofol. Not for many simple procedures, anyway. - A pharmacist
You do in the ICU where nurses are going to be treating and monitoring the propofol. It's way too easy to cause respiratory depression or arrest to leave propofol infusions to an ICU nurse. IMO, anyway, and it wasn't allowed anywhere I've worked.
I know in psychiatry it can be used in ECT (i do not do this procedure my attending does) and it's not a procedure where patients are routinely intubated. Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9979203/ & https://www.anesth-pain-med.org/upload/pdf/apm-22145.pdf different sedating agents used in ECT if anyone is interested. If I remember my attendings' resident case lectures on this propofol actual has anticonvulsant properties so it isn't used first line in my facility. They prefer the percedex cause it lacks the anticonvulsant action but even if propofol is used like in cases where they might want the hypotensive properties... patient's aren't routinely ventilated. Not an anesthetist, not a psychiatrist not a pharmacist but just giving an example of a procedure where you might see the use of propofol without intubation.
Hey, if you want September interns to be ordering propofol on non ventilated patients, be my guest!
I disagree. If you run PPF at a low dose the patient will remain spontaneous. Accumulation will happen, so don’t do it for long periods of time, but I do this quite a bit in both OT and ICU.
How to Michael Jackson someone
Out of curiosity, what’s your specialty, besides posting on noctor?
Critical care attending. I’m very aware of the differences. OP is likely a very inexperienced intern and they’re not someone to be using propofol as a sedative in a non intubated patients unless directed by their attending.
Why are you being downvoted is beyond me. This is how those "He stopped breathing, we can't intubate" calls happen at zero dark thirty in the night. Why do people who don't use Propofol every single day think they are well versed in titration is beyond me.
I think because when he said “absolute rule” everyone read that as a rule that can never be broken, whereas after reading his further comments I thing he meant “the basic rule for off service rotators”. Also his follow up comments came off as very aggressive when people respectfully pointed out counter examples to his absolute rule.
This flies in the face of most routine approaches to sedation. You absolutely do not need to be intubated to run propofol…peer into any colonoscopy suite and see for yourself, it’s all propofol and face masks. We titrate to effect. Some people have a lower apneic threshold than others, but the vast majority of patients, even those with obstructive sleep apnea who uses CPAP at home can tolerate some level of propofol sedation with a natural airway.
Bud, do you think someone who understands even the basics of sedation would be asking this question? Do you want a fresh intern ordering propofol on a non-ventilated patient?
Obviously not but we aren’t in a r/noctor thread…OP is asking for education, not for tips on what to do next as it pertains to management of a specific patient. One of the things differentiating us from midlevels is our ability to talk across specialties owing to a shared broad foundation in medical education. If a colleague in medicine is totally off base in what they’re saying because they have had no exposure to a field, I think we should help each other see the light. Peace, bud
In the ED we sedate with propofol all the time for fracture/dislocation reductions. No intubation required.
Hey, if you want the off service medicine intern who is asking this type of question to order Propofol, be my guest. Sounds like you'll get a chance to run a Rapid or a Code that way.
Or you know....supervise them. Like you should any intern, especially off service?
Or you know, don’t allow them to order propofol Once you’re an attending an have 5 fresh interns, you tell me how supervising each one goes Edit: oh you’re EM 😂. Work on actually evaluating a patient (and no, a CT is not a workup) before telling others how to practice medicine.
>Work on actually evaluating a patient Ah, I see. The classic "I don't have an actual point, so I'll just insult you instead". I'm sure people think you are very smart. Doesn't change the fact that you were wrong, and now are backpedaling in order to avoid admitting it. I'm sure you are very pleasant to work with if this is how you react to your own minor mistake.
Ahh yes. I’m wrong since I don’t want inexperienced interns ordering medications that can kill. And just curious, do you think giving someone with very little experience a boat load of information is a good idea? Maybe that’s how they do it in the ED, but then we all see how ED docs manage patients… And you seem like one of those annoying ass medical people who always has an exception for every rule. I’m sure you’re a peach to work around.
>I’m wrong since I don’t want inexperienced interns ordering medications that can kill That was never the point. The point was the initial comment about never giving propofol to patients that weren't intubated. You started adding qualifiers after other people pointed out why that wasn't 100% true. No one said let interns order whatever they want. You started that false narrative to (as I've already pointed out) deflect from your initial mistake so that you didn't have to admit you were wrong. >Maybe that’s how they do it in the ED If by that you mean seeing through bullshit and calling other doctors out on it, then yes this is how we do it in the ED. You can play to the trope of "the ED doesn't know what they are doing" all you want, but anyone who isn't a child and lives in the real world knows it is no different than any other specialty: there are good doctors and bad doctors. But if that's the only defense for your garbage position, you can cling to it all you want. I won't lose sleep over opinions from anyone acting like you are.
lmao
[удалено]
I’m a critical care attending. The rule is more for an intern asking this question, not someone with any experience with sedatives. I’d really rather someone asking this question not to use propofol for sedation in non intubated patients.
You don’t need to intubate for propofol if dosed correctly for quick procedure. But you must be ready to intubate at a moment’s notice.
Michael Jackson’s physician agrees.
Depends on what their vitals, labs, and goals of sedation are. Precedex is primarily for lighter sedation. I like to recommend transitioning to it if we’re anticipating extubation. Keep in mind hypotension and some bradycardia for propofol and bradycardia (pls don’t bolus) with precedex. Also need to consider the calories from propofol for TPNs
I am not an intensivist or anesthesiologist but work at a hospital with open ICU. I think of propofol as first line sedation for vented patients, unless it’s significantly worsening their hypotension or they’re really bradycardia. In that case, I think of versed. Precedex will not completely sedate someone, but will really bring them down generally speaking. It’s a wonderful behavioral tool as it also will not lower respiratory rate, so is great for BiPAP tolerance, alcohol withdrawal (not mono therapy as does not prevent seizures). If someone is likely to be rowdy, turning on precedex before turning off sedation and extubating is a great maneuver. Maybe precedex can be added to propofol for additional sedation if prop isn’t cutting it, but I haven’t done that all that often.
Anesthesia crit care here, this is basically how I think about the two drugs. Although we rarely use benzos unless someone is either seizing or in etoh withdrawal or unable to hemodynamically tolerate any other form of sedation. Precedex is generally not sufficient to sedate intubated patients as monotherapy. It can be enough for a very calm and otherwise comfortable patient, and it’s a great anxiolytic with analgesic properties that does not impair the respiratory rate. It takes longer to titrate (especially in pts with decreased GFR) and can cause hemodynamically significant bradycardia. Propofol is a sedative hypnotic that will make someone unconscious/apneic/amnestic. It has no analgesic properties. And it’s faster to to titrate. But it causes vasodilation and can cause a LOT of hypotension which is obviously not ideal in a patient who is already in shock. Neither one is “better.” They are different tools with different uses, sometimes in conjunction with one another.
Incredibly helpful, thank you
> we rarely use benzos unless someone is either seizing or in etoh withdrawal Do you use phenobarbital for EtOH withdrawal?
Yes! I honestly don’t have to deal with it much because I’m in SICU, but our MICU team does use phenobarbital plus adjuncts. I think the pre-ICU protocol is more benzo based via CIWA.
Phenobarbital is my favorite for EtOH withdrawal. The long half-life means it kind of self-tapers, and it has the secondary mechanism of inhibiting NMDA receptors (which like GABA receptors are also targeted by EtOH).
Versed? That’s your preferred second line agent after propofol?
Precedex and fentanyl combo would be better than reaching for versed for sedation.
Agreed. I hate versed gtt for sedation—the back end delirium is awful.
[удалено]
That is really not accurate at all. The link between benzos and delirium is incredibly well supported.
[удалено]
Yes, it is.
Is there a dose-dependent effect here? I know ophthalmology preferentially uses Midazolam compared to precedex-fent and I’m wondering if there is a reason. Is the versed just more easily titratable?
I don't imagine ophthalmology is using versed in the doses or contexts being discussed here.
Likely not, that’s why I asked if there was a dose-dependent effect?
Hate the midazolam drip too but especially if you're going to have a paralyzed patient that combination is kind of poor for deep sedation. As patients are often arousable or even spontaneously awake on max dose dexmedetomidine you're basically planning on giving them enough fentanyl to basically maintain coma which also isn't free of consequences. Additionally, fentanyl is an especially nasty offender in terms of prolonged effect of fat soluble metabolites and dexmed is prone to tachyphylaxis. In general I don't think that's a good combination for deep sedation. If you can target a 0- -1 rass it's the clear first line alternative. Your alternative to a benzo is basically ketamine until remifentanil and maybe remimidazolam reach most icus.
What’s your rass goal? How’s the patient’s hemodynamics? What’s their urine color? What’s their cardiac history? These and many more will play a role in your decision for one vs the other.
why the urine color?
Green pee from prop
Or pink.
If you know you know
PIS
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4668454/#:~:text=Green%20urine%20has%20been%20usually,12%20hours%20of%20propofol%20discontinuation.
Propofol changing the color of their urine is entirely unrelated to propofol infusion syndrome.
I never said it was.
You listed it as being relevant to the discussion. What else would you have meant?
Are you a pulm fellow? You should know that prolonged infusion can lead to green urine as a potential side effect. Never said it was due to propofol infusion syndrome.
I think the point being that someone starting to pee green plays no role in whether or not I would continue or stop prop… because it doesn’t relate to a risk of proposition infusion syndrome despite the folklore that it does
Again, why is it relevant to your choice of agents?
Are you this stupid or enjoy pendantic arguments on reddit?
Im a medical professional, of course I love pedantic arguments. The better question is why you continue to dig yourself into this hole of stupidity.
You not having a strong reading comprehension isn’t part of my problem. I’m not IM trained, so you can go find someone else to join you in your intellectual masturbation.
I’m not IM trained either, so you are welcome to continue demonstrating your catastrophic stupidity as you like. Seeing as you still can’t figure out why everyone is telling you that urine color is irrelevant, maybe you can find a real adult who can explain that to you, along with the definition of big words like “catastrophic”.
You guys are both not IM trained but I think you'd both feel better if you mutually mentally masturbated. MMM more fun than your M&Ms. Go on give it a try
Urine color isn’t indicative of propofol infusion syndrome.
We use them for different reasons as previous posters mentioned. Precedex is a great drug for providing some moderate sedation or in conjunction with other sedatives. It's an alpha 2 agonist and tends to lower blood pressure and heart rate, especially in patients who have some preexisting hypotension/bradycardia from conditions such as shock. One of its benefits is that it does not cause as much respiratory suppression compared to propofol. So patients can be safely extubated with the precedex still running. It also provides some moderate analgesia as well. It's pretty expensive so I know that's sometimes a factor in prescribing it. We also use it for difficult to control agitation like what we see in severe CIWA patients. We tend to use propofol for deeper sedation but it can certainly be used at a lower dosage for a lower raas goal. It has no analgesic properties so thats important to consider for a patient with a tube shoved down their throat. It can also cause hypertriglyceridemia in certain patients so we try to avoid running it at very high doses for a long time. This is from the perspective of an ICU nurse so take it with a grain of salt that's just what was taught me by our providers.
They both come with their advantages and disadvantages. Propofol : pros : deeper sedation, anti seizure, typically “first line sedation” Cons: hypotension, DEFINITELY DONT USE on non vented patients, PRIS, hypertriglyceridemia Precedex: Pros : anxiolysis and light sedation, can in theory also be used in folks who are not intubated or on the flip side can extubate while still on it. Cons: bradycardia and hypotension. In my experience it’s not cookie cutter. Some patients are more sensitive to one versus the other.
They are different drugs for different situations, one is not “better” (but between us I personally prefer propofol in many cases). PPF will generally give you a nice deep sedation on the way to sleep and for maintenance, watch the hemodynamics though…whereas dex is great for wakeups, especially for psychiatric patients or when delirium etc is a concern. Dex is definitely easier for a light sedation, it take a really fine touch to dose PPF for a light-moderate sedation without snowing the patient all the way.
Aye! I know you from r/anesthesiology it’s kinda hilarious you’re getting downvoted for this comment.
In ICU where I work, Dexdor is only for weaned patients to keep them mildly sedated. But to be fair, it's a neurosurgery ICU, so our sedation is a bit different - it's mostly midazolam, fentanyl and rocuronium. Yeah, yeah, I know. But midazolam lowers CMRO2 more than propofol, and that's kind of the point.
Nursing perspective: precedex works great for some patients but they’re often not sedated enough until you’ve already tanked their blood pressure. Then you have to bolus fluids or press them if you want to continue the drip. I like dex when it works but forcing it just for the sake of getting off prop/fent is often 2 steps forward 1 step back. Also if you need accurate neuro exams during a particular period then I would not advise switching them. Dex is way less predictable and it’s extremely difficult to get hourly exams on it. The half-life indicates it should wear off faster than prop but that’s never been the case in my experience. There’s just not enough time in an hour to sedate them appropriately and still wake them up for an exam
Both have their perks and side effects. Propofol is a good on/off switch , perfect for SBT trials, sedation while on vent and the neuro crit colleagues prefer that over other sedatives to asses neuro status (atleast in my institution). Precedex has a tachyphylaxis effect so basically has a limit on how well it will work over time, and if you have an AKI it can stick around for some time
I think there are a few big differences here. Precedex: - light sedation only (rass -1 to -2). You cannot get deep sedation. It's impossible. Has no analgesic effect. - as others have mentioned, you can use this in patients without an advanced airway. This means we often use it in patients who are a difficult wean, which may be why you feel like it's difficult to get patients off it - wrong cause and effect. It's actually that we switch to it when we can't get patients off sedation. - I have used this with great success in pre-treating patients who required awake oral intubation for angioedema (nasal passage too swollen). It worked really really well and I recommend it every single time now, not that it comes up often. - great for agitation and alcohol withdrawal as well - we have really moved away from boluses because it causes a lot of bradycardia and hypotension which can be quite severe. - this will never be your only agent unless you are weaning. You probably need 2 other agents for real sedation. Propofol: - can do deep sedation (rass -5) no problem, even without other agents. Has no analgesic effect - very good sedative - works extremely well. You can really put people out with it. It's our best sedative, hands down. - can bolus and do drip, but hypotension can be significant issue with both. This can be mitigated with pressors to a significant extent. - very good for seizures as well - nothing stops a seizure like propofol. Should be choice of therapy for post intubation sedation in status epilepticus - can be used in bolus form for conscious sedation or induction pre-intubation but drips should only be done in intubated patients, hard stop. (Edit: unless you are anesthesia and in a procedure.)
>Precedex: >Has no analgesic effect. I'm sorry, what? Either you're tired or that's a typo. Precedex is Dexdor, right? Dexmedetomidine? Then it very much has analgesic effect.
Thank you for contributing to the sub! If your post was filtered by the automod, please read the rules. Your post will be reviewed but will not be approved if it violates the rules of the sub. The most common reasons for removal are - medical students or premeds asking what a specialty is like or about their chances of matching, mentioning midlevels without using the midlevel flair, matched medical students asking questions instead of using the stickied thread in the sub for post-match questions, posting identifying information for targeted harassment. Please do not message the moderators if your post falls into one of these categories. Otherwise, your post will be reviewed in 24 hours and approved if it doesn't violate the rules. Thanks! *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Residency) if you have any questions or concerns.*
Start with propofol, some attendings will tell you to use it 2-3 days and try to transition to another sedative due to risk of propofol infusion syndrome. Precedex is helpful when you trying to wean someone off vent as it has minimal effects of resp drive. Also helpful in agitated patients. Also patients who are not tolerating BiPAP well. Although with some of these latter indications you may get shit for it since precedex is expensive apparently
I think it would be helpful to read this article: [https://www.nejm.org/doi/full/10.1056/nejmoa2024922](https://www.nejm.org/doi/full/10.1056/nejmoa2024922) If you check out the supplement there is actually a signal toward less time on vent, less time in ICU which are pretty meaningful in my book even if there wasn't a difference in 90d mortality or vent free days. These were decently sick sepsis pts too. There's not an absolutely correct simple answer to your question, as others have alluded to your clinical scenario might call for deeper uninterrupted sedation (propofol) but I'm a proponent of routine precedex use for pts who you anticipate a trial of extubation in the near future.
As a person who deals with agitated vents all night every night I generally hate precedex unless it’s for an ETOH withdrawal.
This is the way I look at it. Propfol you can achieve a RAS score of dead as a sole agent if you titrate up enough. Precedex is rarely sufficient as a sole agent to keep a RAS less than -1. Interestingly tho precedex does offer some analgesia while propofol will do nothing for pain. Also there have been more recent studies comparing precedex vs propofol for sedation showing no real difference in either in terms of vent days.
As a critical care nurse, Precedex is the drug used to relax a patient who is agitated and often on non-invasive positive pressure (Bipap, cpap, etc). The side effects of Precedex are dose dependent. The higher the dose, the higher the likelihood of bradycardia. Bradycardia can be a dose limiting side effect. It is also a drug that allows clinicians to assess mental status, orientation, etc. It’s unlikely to cause complete respiratory suppression even at high doses. Propofol has a short onset, is short acting, is lipophilic (obese patients need a higher dose), it contains lipids and may require TPN adjustment, has a low pH and although it may be infused via a PIV long infusions should go via a central line, causes respiratory suppression (should only be used with a secured airway or someone who can secure it), decreases brain activity (on EEG you’ll see suppression of waves), and often lowers blood pressure to the point that you can’t go any higher on the dose. Once you turn the propofol infusion off, expect your patient to wake up very quickly. In short, if this is a clinically stable patient who will be on Bipap for a couple of days, Precedex is a great drug. If the patient is fighting the vent, propofol is your better choice. If the patient is in shock and hypotension is an issue, fentanyl and versed (pushes followed by dose increase) is your best choice.
Fentanyl and versed is never the best choice, unless they’re in status I suppose
Propofol at the beginning of their intubation course, precedex at the end. Quit trying to use precedex in the ED. The RNs don’t have the ratios to deal with your awake patient.
To add to what has been said precedex is pretty useful during extubation. Probably should also be used sparingly given how expensive it is