Things that make you go hmmm.

[tniuqs]

But then again it could be the well know syndrome O.S.P.S.

Commonly refered to as One Sick Puppy Syndrome.

So do I win a prize ? Like a all expense paid holiday vacation to Afganistan? :shock:

I have not seen AK in a while. 8)

[p3medic]

Vent got this one earlier. Lets stop the propofol, hydrate and sedate with a benzo/opiate. Propofol is the likely culprit.

[chbare]

Looks like we nailed the cause. What is going on with this guy?

Take care,

chbare.

[fireflymedic]

here's my thoughts - the rhabdo is causing the metabolic acidosis. The thoughts crossed my mind earlier, but at any rate - I'm still suspect that there's not some sepsis going on.... labs still make me think that direction. If diprivan is processed through liver - and liver affected, it is contributing to the problem. You state propofol was given for 48 hours - not that long, but long enough with liver compromise. The stress of trying to process the diprivan is contributing to the metabolic acidosis as well. IMHO - this is one very sick guy. Glad you're flyin with him and not me !

[chbare]

Let us take the diprivan consideration a step further. Does this patients condition fit with any of the complications associated with diprivan use? A syndrome perhaps? I know a few members already know the problem, thanks for allowing additional conversation that will hopefully benefit people who have never herd of this problem.

Take care,

chbare.

[fireflymedic]

CB - propofol infusion syndrome - by chance do we have green pee? He definitely fits the bill here - critically ill patient, long term propofol, tachycardia (though bradycardia is an effect sometimes as well), myoglobinuria, rhabdo, and metabolic acidosis. Sounds like he fits the bill pretty well. Took me a bit to get there, but I think we did. One fun side note though, when was last time tubing was changed? Diprivan is known to be bacteria friendly especially if tubing not changed every 12 hours - could he also have some little critters growing in there? Just curious. You made my brain hurt CB ! Good scenario though.

Oh, as far as what to do about it? Is changing sedation to versed/fentanyl an option? That would be my preferred way to go anyway since this guy's been down and prolly gonna stay down for a bit - will they be doing daily awakenings or no? If not, let's change the ticket here and problem resolved !

[VentMedic]

I've seen the green pee only a couple of times and it did not seem to accompanied by any adverse affects. We are also strict about our tubing changes.

Propofol infusion syndrome has the been the required reading lately for us in the ICUs since the article ran in a couple of different CC journals.

Personally I believe since Propofol has become almost "routine" in some ICUs, we will start to see more adverse effects. Before it was very controlled and limited to the OR and a few advanced practice ICUs. Now it is in almost every local general's ICU if cost is not a concern. However, many of our EDs will not set up a drip even on ventilator patients which usually for the COPD or CVA pt it is not needed. Even with an ED holding area for 6 - 8 ventilators, we can manage with other sedation and pain management. Those that need propofol usually go to the OR directly from the OR or to the trauma ICU.

We use propofol in high doses for many days if we have must just to get a patient through a difficult stretch especially if we are doing an aggressive ARDSnet or HFOV. If the patient is also a complex surgical patient, it takes creative pain management to accomondate whatever intense ventilation strategy imposed on them as well. We try to avoid paralytics except when the O2 consumption and/or synchrony are of serious concern.

Are Paramedics allowed to monitor and/or titrate propofol on ground CCTs? They still require an RN to accompany in my area and the areas I am familiar with in California. For Flight, it is not used for HEMS and those that are able to do interfacility have RNs on board.

[fireflymedic]

Here can titrate to effect if CCT - not a regular medic transfer. Run of mill medic can't even take propofol. Was just curious about green pee Vent Medic 'cause I know it's been seen in pt's over 48 hours - had one not too long ago that I posted about that was a transfer pt of mine. I'm definitely suprised to see how commonly it's used, but the quick on quick off action is probably what is making it so popular within ICU's - requires much less wear off time. Also, transport a pt on diprivan and you can wake them up to do neuro checks as needed so I can see the benefit to that whereas with other sedation especially depending on size of patient and length on it may take considerably longer. I am curious - was changing the sedation an option here CB or were you forced to stay with what you had? If you gave us fentanyl earlier, you could even give a bit more fentanyl for sedation/analgesia and back off the diprivan some. Just thoughts.

[chbare]

Propofol infusion syndrome has the been the required reading lately for us in the ICUs since the article ran in a couple of different CC journals.

Personally I believe since Propofol has become almost "routine" in some ICUs, we will start to see more adverse effects. Before it was very controlled and limited to the OR and a few advanced practice ICUs. Now it is in almost every local general's ICU if cost is not a concern. However, many of our EDs will not set up a drip even on ventilator patients which usually for the COPD or CVA pt it is not needed. Even with an ED holding area for 6 - 8 ventilators, we can manage with other sedation and pain management. Those that need propofol usually go to the OR directly from the OR or to the trauma ICU.

Agreed, the incidence of PRIS appears to be on the increase. I also suspect this is related to the fact that we are starting to use diprivan quite frequently outside of the OR and specialty units. I even see patients frequently go on Diprivan following intubation in the ER.

I hope everybody enjoyed this scenario. Hopefully, we can use this to realize that pharmacology is a dynamic field and we should strive to understand the problems associated with the medications that we give to our patients. In addition, new problems associated with medications we are accustom to using can occur. Additionally, things do not always fit into the nice box we are so often taught. Hence the title of this thread. We should also strive to stay on top of the newest literature.

Firemedic, looks like you nailed the diagnosis.

Take care,

chbare.

[VentMedic]

If only CC Medicine was that easy. This scenario can be continued to great length. If 50 mcg/kg/min of propofol was allowing the patient to still breathe more than 2x the vent settings (luckily to correct pH), whatever alternative sedation/pain meds that are liver and gut friendly may have a difficult time holding him for synchronous ventilation by a transport ventilator. Thus, more aggressive BP management may need to be in place to maintain MAP. But, without the advantages of a CVP monitor, the patient my still be need fluids or NOT and that fine line of fluid homeostasis may be crossed. Paralytics may also have to be considered but again that does not negate the need for increased sedation/pain management.

Unlike EMS where you usually have only one working dx to run with, CC medicine has multiple issues to be concerned with for present and proactive. Every body system, medication and even the ventilator must work together. Whatever adjustment is made to the ventilator may rock the sedation/pain/hemodynamic aspects of the patient. Likewise, any titration, up or down, of the meds may have a profound effect on ventilation and oxygenation.

Even in the controlled environment of the ICU, scrapping one plan to start with another may mean several more hours of fine tuning the patient back to where everybody is satifisfied that the patient is somewhat stable or more stable than before.

In some ICUs it may take several hours to round on high acuity patients to make sure MDs, RNs, RRTs, Pharmacists and Dietitians are all in agreement and on the same page in the treatment plan.