Propofol for procedural sedation

[always.chillin]

Who TF are y’all’s patients? I rarely have to give more than 1mg/kg. I commonly start at 0.5 and achieve adequate sedation for a quick ortho procedure. I can’t recall the last time I’ve had to redose past 1.5mg/kg total.

Usually obese with multiple comorbidities and often intoxicated.

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[EmergentMagician]

Second the ketofol approach-

I pull up a syringe of 2mg/kg propofol and separate syringe of 2mg/kg ketamine

I start with the propofol, 1mg/kg bolus. Sometimes this is enough and I just stay there, perhaps with some further 20mg doses of propofol.

If they are proving pretty resistant to the 60-100mg propofol bolus, then I give 0.5mg/kg ketamine.

This works beautifully, every time. Starting with the propofol prevents the untoward sub-dissociative yelling/dysphoric effects of the ketamine, and patients wake up much more calm than if we went with ketamine alone.

 

[EmergentMagician]

Forgot to mention another fun approach:

I had an anesthesiologist I used to work with, who sometimes would have to come to the ED to run sedation (due to occasional lack of available sedation qualified RNs)

He would inject a bottle of ketamine and a bottle of propofol into a 100cc bag (I forget the doses), and then would just run a dirty drip titrated to effect. Was pretty elegant.

 

[TrailRun]

I think the max I've given or would feel comfortable is about 250. Almost never need more than 200. To the poster above, I personally wouldn't feel comfortable giving 200 to a 30kg child, would have aborted the procedure long before that. I'm almost always single coverage in a place with no peds or in house anesthesia. Would never intubate just to facilitate a reduction. The times I've run into trouble usually have been successful reduction that then falls out again multiple times and ultimately needs ortho/OR.

 

[alpinism]

Agree with the other posters.

There's a lot of variation with propofol dosages needed for sedation. I've given everything from under 50 to over 500 to do fracture reductions.
Where I work in an inner city knife and gun club almost everyone is high on drugs and routinely needs 250+ just to fall asleep. As long as you can titrate with small doses and manage the airway at the bedside it's actually quite safe. There really isn't any reason to ever utilize the OR in these cases unless nonsurgical reduction is not possible and the patient genuinely needs the OR for a surgical open reduction.

 

[EctopicFetus]

at an old hospital i would work at the GI guys would sometimes do food boluses in the ED. I gave some dude 900mg+ of propofol to get him good for his scope. Personal record.

Also agree its not uncommon to have to give over 1mg/kg.. Will usually start with 0.5ish.. just yesterday had a lady.. about 70kg.. started with 50 of propofol.. needed a little more to get her right for her ortho procedure. Much depends on the specifics of the procedure. Some take longer (or expect to) some are short.. If I have to sedate for a procedure i think will take a while or they need to be a little more sedated I’ll add the ketamine. I’m a fan of ketofol though last I looked the literature didnt really support its use.

 

[Janders]

I think the max I've given or would feel comfortable is about 250. Almost never need more than 200. To the poster above, I personally wouldn't feel comfortable giving 200 to a 30kg child, would have aborted the procedure long before that. I'm almost always single coverage in a place with no peds or in house anesthesia. Would never intubate just to facilitate a reduction. The times I've run into trouble usually have been successful reduction that then falls out again multiple times and ultimately needs ortho/OR.

It was a badly deformed forearm fracture with a cool hand and no palpable pulses. No kiddy anesthesia or Ortho here, needed to perfuse hand and transfer. It was amazing how much propofol she soaked, but what are you going to do… (I guess I could have started with ketamine, but I didn’t really want her gone for 45min when I wanted her awake and in an ambulance driving to definitive care).

 

[Zebra Hunter]

I used to do the 0.5 mg/kg initial bolus and then additional boluses after if needed, but found I was consistently getting inadequate sedation with this method, and usually having to give significantly higher doses than if I just went high initially.

I’ve switched to 1 mg/kg as the initial dose a few years ago and rarely if ever am I having to re-dose, and when I do re-dose, I’m typically giving fairly large doses rather than small boluses. It has also obviously led to significantly improved reductions. I haven’t had to tug on a shoulder in a while. I’ve found that with enough sedation with propofol, most of these shoulders will spontaneously reduce without need for reduction.

 

[GassYous]

Why don't you just give a small dose of sux

 

[EctopicFetus]

Why don't you just give a small dose of sux

Or vec. Thats the Vanderbilt protocol….

 

[BoardingDoc]

Or vec. Thats the Vanderbilt protocol….

Ba-dum-tiss. Seriously though, that was a horrible way to die. You're claustrophobic so they give you versed before your MRI, except instead of versed, it's Vec. Sheer horror for your last moments on earth.

 

[gruemd]

Why don't you just give a small dose of sux

Pretend like I'm a dumb ER doc who hasn't used sux for that before, what constitutes a small dose? I'm guessing it just causes a partial effect --> Muscle relaxation?

 

[Sleeplessbordernights]

Bumping this thread to get some thoughts. Let’s say you have a hip dislocation. Patient absolutely needs sedation for reduction. After a total of 2.5 mg/kg of propofol patient still not sedated enough. You then add 1 mg/kg of ketamine. Still not sedated enough and reduction fails. At this point, you’re nervous to give more. Do you just admit the patient to have OR reduction with anesthesia or intubate the patient yourself and reduce? I’ve had this happen a few times. I always just admit and have it done in OR and after reviewing the chart anesthesia has always intubated the patient for reduction. The problem is ortho always gets upset and tells me “patient not sedated enough.” I frankly don’t have time to intubate a patient for a reduction and try to extubate in the ER.

Not an EM doc but anesthesia one…how about a quick peng block plus your standard dose of propofol? Maybe less since in theory he/she won’t be in as much pain if at all

 

[Arch Guillotti]

Pretend like I'm a dumb ER doc who hasn't used sux for that before, what constitutes a small dose? I'm guessing it just causes a partial effect --> Muscle relaxation?

20-40 mg. Complete muscle relaxation for a very brief period of time.

 

[RustedFox]

Not an EM doc but anesthesia one…how about a quick peng block plus your standard dose of propofol? Maybe less since in theory he/she won’t be in as much pain if at all

WTF is a peng block?
Go back to the O.R. - it's dangerous here for you.

[said in a tone to convey friendly ridicule]

 

[Arch Guillotti]

Forgot to mention another fun approach:

I had an anesthesiologist I used to work with, who sometimes would have to come to the ED to run sedation (due to occasional lack of available sedation qualified RNs)

He would inject a bottle of ketamine and a bottle of propofol into a 100cc bag (I forget the doses), and then would just run a dirty drip titrated to effect. Was pretty elegant.

He sounds foolish. Propofol and ketamine drips aren’t exactly sedation most of the time.

 

[Groove]

I’m 50mg bolus and 25mg slow pushes for sedation with bumps of 10mg to maintain for procedure. Most I ever needed was 600mg in a 70ish kilo young female who just drank that stuff up. It was wild.

 

[ShockIndex]

He sounds foolish. Propofol and ketamine drips aren’t exactly sedation most of the time.

If your point is that these drips typically cross over into induction of general anesthesia and deep sedation, then I tend to agree.

I like prop for certain procedures and believe that it should be part of the EP armamentarium. However, I feel like EPs are being poorly served by hospitals that make it available but restrict EP privileges to ASA “moderate sedation” which does not fit the reality of the typical ED patient who needs prop.

IMHO, prop (and similar barbiturate anesthetics) is often the ideal agent for proximal joint reductions that require complete relation that can only be achieved by deep sedation or even general anesthesia - for 1 minute. In these patients, you are best to give a single, larger dose of prop that is typically 1-1.5 mg/kg. However, in doing this the EP will often blow right through moderate sedation and land, at least for a minute or two, in deep sedation or even general anesthesia territory. As long as the EP is prepared for this and the period is brief, this is safe in the ED. By prepared, I mean the EP has pre-oxygenated the patient, has appropriate ETCO2 monitoring, and is physically positioned to support the patient when they briefly lose their airway and respiratory reflexes for a minute or two. The EP cannot be trying to simultaneously tug a leg, jaw thrust, and bag a patient when doing this - multiple operators are necessary.

Where EPs get into trouble is when they slowly “titrate” prop for longer procedures such as EGDs, or get roped into repeated reduction attempts by ortho residents who want every upper level to tug on a leg before waking their attending up to book an OR case. This is where EPs can and do rarely MJ a patient (I’ve seen 2 cases in 20 years of bad, bad outcomes from prop shenanigans). There are a lot of strategies to avoid this that depend on local environment, but a common starting place is recognizing when our colleagues are asking us to do something dumb because they or the hospital are too cheap to properly staff the anesthesia department.

 

[CoolDoc1729]

I’m 50mg bolus and 25mg slow pushes for sedation with bumps of 10mg to maintain for procedure. Most I ever needed was 600mg in a 70ish kilo young female who just drank that stuff up. It was wild.

The same weekend I had two ankle fx dislocations … the small older woman required 400 and the big younger man went briefly apneic with 80 .. 🤦🏻‍♀️

my usual practice is 60 and then 20-30 boluses, unless they are tiny and/or old and then I have done more like 40 with boluses of 10-20.

 

[GassYous]

Why don't you guys give any versed or fentanyl

 

[ShockIndex]

Why don't you guys give any versed or fentanyl

We do - when it’s appropriate. But this is a thread that specifically asked about how we choose to employ propofol. That doesn’t mean that we can’t or won’t use other agents when appropriate. When there is a thread on the anesthesia subforum asking about how someone uses isoflurane, do EPs wander over and start asking, “Why don’t you guys ever use more laughing gas?”

Many of our procedures are brief, lasting under 2 minutes, and propofol is more appropriate because it is associated with shorter recovery and ED length of stay. Propofol is also more ideal for those patients who need deep sedation or general anesthesia for under 5 minutes than versed/fent.

 

[Arch Guillotti]

If your point is that these drips typically cross over into induction of general anesthesia and deep sedation, then I tend to agree.

I like prop for certain procedures and believe that it should be part of the EP armamentarium. However, I feel like EPs are being poorly served by hospitals that make it available but restrict EP privileges to ASA “moderate sedation” which does not fit the reality of the typical ED patient who needs prop.

IMHO, prop (and similar barbiturate anesthetics) is often the ideal agent for proximal joint reductions that require complete relation that can only be achieved by deep sedation or even general anesthesia - for 1 minute. In these patients, you are best to give a single, larger dose of prop that is typically 1-1.5 mg/kg. However, in doing this the EP will often blow right through moderate sedation and land, at least for a minute or two, in deep sedation or even general anesthesia territory. As long as the EP is prepared for this and the period is brief, this is safe in the ED. By prepared, I mean the EP has pre-oxygenated the patient, has appropriate ETCO2 monitoring, and is physically positioned to support the patient when they briefly lose their airway and respiratory reflexes for a minute or two. The EP cannot be trying to simultaneously tug a leg, jaw thrust, and bag a patient when doing this - multiple operators are necessary.

Where EPs get into trouble is when they slowly “titrate” prop for longer procedures such as EGDs, or get roped into repeated reduction attempts by ortho residents who want every upper level to tug on a leg before waking their attending up to book an OR case. This is where EPs can and do rarely MJ a patient (I’ve seen 2 cases in 20 years of bad, bad outcomes from prop shenanigans). There are a lot of strategies to avoid this that depend on local environment, but a common starting place is recognizing when our colleagues are asking us to do something dumb because they or the hospital are too cheap to properly staff the anesthesia department.

A “drip” and ketamine is stupid for a procedure that is so brief.

 

[Janders]

A “drip” and ketamine is stupid for a procedure that is so brief.

Tend to agree.

Pretreat pain with fentanyl, and single agent propofol to dance at the edge of deep sedation briefly is all I need for 90% of ED sedation needs (reduction, cardio version, very painful I&D, etc).

The main exception is the toddler that needs a significant laceration repair. Ketamine and it’s length of action is perfect for these cases.

 

[southerndoc]

20-40 mg. Complete muscle relaxation for a very brief period of time.

I wish we were credentialed to use this for procedural sedation.

 

[jwk]

I wish we were credentialed to use this for procedural sedation.

Honest question - are you guys credentialed to do general anesthesia in the ER? Because this is what some are clearly doing.

 

[thegenius]

Honest question - are you guys credentialed to do general anesthesia in the ER? Because this is what some are clearly doing.

No

 

[skougess]

Honest question - are you guys credentialed to do general anesthesia in the ER? Because this is what some are clearly doing.

Yeaaaah. Giving paralytics for ER procedural sedation? Just wild.

 

[Mount Asclepius]

This is the problem. Hospitals and credentialing bodies like to put way too narrow of limits on what we do in the ED. Like you can’t perform general anesthesia, but yeah go ahead and help someone in respiratory failure with an intubation. We’ll let you do deep sedation then. But wait, don’t use a BVM for 2 minutes while the Propofol wears off when you are putting that hip back into place.

They then ask, why do you admit so many patients? Can’t you just take care of it in the ED. Ohh, but we don’t think you should use Propofol. Or, don’t do transient deep sedation, despite the fact that we are fully trained and capable of both recognizing and managing apnea and airways.

 

[Zebra Hunter]

Honest question - are you guys credentialed to do general anesthesia in the ER? Because this is what some are clearly doing.

Try putting a hip in without putting the patient under general anesthesia. It’s essentially impossible. Everyone calls it “moderate sedation” or “conscious sedation”, but we all know it’s general anesthesia.

 

[Arch Guillotti]

I wish we were credentialed to use this for procedural sedation.

I love it. Paralytic for sedation.

 

[ShockIndex]

Honest question - are you guys credentialed to do general anesthesia in the ER? Because this is what some are clearly doing.

see post #68.

 

[southerndoc]

Try putting a hip in without putting the patient under general anesthesia. It’s essentially impossible. Everyone calls it “moderate sedation” or “conscious sedation”, but we all know it’s general anesthesia.

If you start with procedural sedation and patient turns into general anesthesia because you accidentally gave too much, then that's acceptable. To use paralytics or purposefully put someone in deep sedation, that is beyond what most hospitals credential providers to be able to do.

 

[thegenius]

Very weird opinions about sedation and (or vs) general anesthesia put forth above.

 

[Zebra Hunter]

Very weird opinions about sedation and (or vs) general anesthesia put forth above.

Say what you mean, man.

I’m assuming you’re talking about several of us talking about putting patients under brief deep sedation/general anesthesia for procedural sedations. The reality is, every single ER doctor does it. I would say many, if not most, have no clue that they are technically not performing “moderate sedation” for a large percentage of their sedations. If your patient is out like a light during your sedation, that is not moderate, that is deep sedation or general anesthesia. We all claim “moderate sedation” because that is what we are credentialed for, but some of our uptight anesthesia colleagues would likely frown at at us yanking on someone’s dislocated shoulder while they have zero or minimal response and then subsequently claiming the patient was under moderate sedation.

It’s just something that we all do that is technically against the rules, but is also necessary to perform our job appropriately. Obviously weigh the risks and benefits carefully in patients you believe will need deeper sedation, have plenty of monitoring, and have a low threshold for bailing on the procedure to manage the airway, or better yet, if not single coverage, have a colleague in the room to assist with the airway if necessary.

 

[thegenius]

Say what you mean, man.

I’m assuming you’re talking about several of us talking about putting patients under brief deep sedation/general anesthesia for procedural sedations. The reality is, every single ER doctor does it. I would say many, if not most, have no clue that they are technically not performing “moderate sedation” for a large percentage of their sedations. If your patient is out like a light during your sedation, that is not moderate, that is deep sedation or general anesthesia. We all claim “moderate sedation” because that is what we are credentialed for, but some of our uptight anesthesia colleagues would likely frown at at us yanking on someone’s dislocated shoulder while they have zero or minimal response and then subsequently claiming the patient was under moderate sedation.

It’s just something that we all do that is technically against the rules, but is also necessary to perform our job appropriately. Obviously weigh the risks and benefits carefully in patients you believe will need deeper sedation, have plenty of monitoring, and have a low threshold for bailing on the procedure to manage the airway, or better yet, if not single coverage, have a colleague in the room to assist with the airway if necessary.

There are assertions that I never would have guessed. I would never have guessed that "most have no clue they are performing moderate sedation", "we all claim that moderate sedation is what we are credentialed for," and some other comments above as well.

Are you not credentialed for deep sedation? I'm credentialed for both, but not general anesthesia. I rarely do "moderate sedation", almost exclusively do "deep sedation." I occasionally give someone ativan 1mg PO for a lac repair, and I routinely give versed 2mg IV for an LP. I consider both of those moderate. But everything else is deep. I'm surprised people on here claim that propofol for a joint reduction might be considered moderate sedation? There are very weird opinions as I said.

And yea I think it's weird too that a standard adult can take up to 600 mg propofol without batting an eye? WTF? That's never happened to me I've been doing this for 14 years.

I'm not here to argue with you. I guess there's a mix of anesthesia and ER commenting on things here. I never would have asserted anything above in bold or in many other comments on this thread.

 

[Mount Asclepius]

The vast majority of EPs aren’t allowed to do deep sedation from a credentialing standpoint, but we all do it briefly and routinely without batting an eye. The line between moderate and deep is fine, but it requires a trip down the rabbit hole to get the job done. If Anesthesia wants the turf fight then they can come to every single ED sedation in the middle of the night.

 

[thegenius]

The vast majority of EPs aren’t allowed to do deep sedation from a credentialing standpoint, but we all do it briefly and routinely without batting an eye. The line between moderate and deep is fine, but it requires a trip down the rabbit hole to get the job done. If Anesthesia wants the turf fight then they can come to every single ED sedation in the middle of the night.

Again where you get this information? I've been credentialed (including residency) at 5 hospitals in my life and always been credentialed specifically for deep sedation.

There are 40,000 - 50,000 Emergency Physicians in the US. How do you know the "vast majority" of their credentialing status?

Right now I work with about 55 other EP docs at three hospitals and we can all do deep sedation. (One of them is Kaiser and I'm willing to bet that Kaiser EP's across Northern California can all do deep sedation.)

 

[Mount Asclepius]

Again where you get this information? I've been credentialed (including residency) at 5 hospitals in my life and always been credentialed specifically for deep sedation.

There are 40,000 - 50,000 Emergency Physicians in the US. How do you know the "vast majority" of their credentialing status?

Right now I work with about 55 other EP docs at three hospitals and we can all do deep sedation. (One of them is Kaiser and I'm willing to bet that Kaiser EP's across Northern California can all do deep sedation.)

55 out of 40,000-50,000 EPs.

How many of you EPs out there are credentialed for more than moderate sedation (when not performing intubation)?

I agree, every board certified EP can and should do deep sedation when doing safely and appropriately.

My only point is that it is an area where many EPs are technically hamstrung by credentialing policies.

 

[skougess]

As another data point, I’m credentialed for deep sedation. *shrug*

 

[BJJVP]

I am credentialed to sedate patients in the ED. How deep they can be sedated is anybody's guess because I frankly didn't read my credentialing papers that carefully. I do know that we are expected to sedate when necessary. My general rule is that if I have to bag them, then I probably went a little too far. If I had to intubate them, then the case will get looked at. I have never heard of using paralytics and have never really seen the need though. But, to be fair, I also have never felt the need to use ketofol either.

 

[Janders]

I have no idea what the ABEM GENERAL average EP's credentialling packet and hospital sedation policy looks like. I know mine like the back of my hand though--

We based our sedation credentialling (which I had to rewrite a decade ago when the ED couldn't use propofol even on intubated patients, and couldn't use ketamine in any form) on the ACEP guidelines, which are quite reasonable and thus with proper politics I was able to use as the blueprint to write a local policy. This policy has up nicely during every joint commission and DPH eval.

Specifically we are credentialed to do "PROCEDURAL SEDATION" and that is what we do, trying to avoid the separate hospital policy for "moderate sedation" which is typically for GI to do low risk outpatient endoscopy. Often that policy is full of annoying things like ACLS requirements, medication dosing requirements, "moderate only" language, two-provider language, etc. Within the policy there is discussion of moderate, deep, general and dissociative.

We commonly do procedural sedation to the level of moderate and deep sedation (its a continuum). You can ABSOLUTELY do moderate sedation w/ propofol. If you can shake the patient awake and they follow a command, that's moderate sedation. I often do elderly shoulder dislocations at that level, as they usually don't need to go deeper. That said most propofol sedation we do in the ED gets to the level of deep sedation. This is fine and safe when done properly. Classic moderate sedation is fentanyl versed, which I haven't done in... about 10 years, when I got this policy through committees and got my hands on some prop.

I do disagree with the above poster who noted a low dose of ativan or versed is "moderate sedation". Absolutely not. That's anxiolysis. Or perhaps, if you give them a decent dose, "minimal sedation".

The policy hasn't been updated since 2018 so could probably use a polishing, but its a good framework--

https://www.acep.org/siteassets/new-pdfs/clinical-policies/clinical-policy-procedural-sedation-and-analgesia-in-the-emergency-department.pdf

 

[Janders]

Also I don't do paralysis when I do sedation. I ABSOLUTELY agree it would help with a hip dislocation. This is usually why I call anesthesia and Ortho takes them to the OR... so they can do anesthesia and paralyze the patient and get the hip in.

Could an EP do this safely? Sure. I do find it playing with fire, however. Certainly you would need two providers with one solely doing the... anesthesia.

 

[CoolDoc1729]

Also I don't do paralysis when I do sedation. I ABSOLUTELY agree it would help with a hip dislocation. This is usually why I call anesthesia and Ortho takes them to the OR... so they can do anesthesia and paralyze the patient and get the hip in.

Could an EP do this safely? Sure. I do find it playing with fire, however. Certainly you would need two providers with one solely doing the... anesthesia.

Agree .. I don’t know if I am allowed to give paralytic as part of a “sedation” plan but I have never and do not intend to do so unless I am planning to intubate anyway for whatever reason … seems dicey from my perspective as a single covered night doc

 

[southerndoc]

As someone who sits on med exec committee and was a former credentials committee member, I can assure you we did a lot of research and the vast majority of hospitals do not credential providers for deep sedation. It's actually quite comical because moderate sedation says that patients not only maintain their own airways, but they should be able to follow commands. Yeah right, every sedation is a deep sedation regardless of what you're credentialed for.

 

[Groove]

And yea I think it's weird too that a standard adult can take up to 600 mg propofol without batting an eye? WTF? That's never happened to me I've been doing this for 14 years.

Yeah, it was super weird. Maybe she was 80 kilos. It was a gnarly colles fracture/dislocation which I will consult ortho on rare occasion. I've never even remotely come close to needing to give this kind of dose. This was over about 20 mins or so. Luckily, we had a third bottle ready. I was about to stop the case honestly...I thought there was something wrong with the prop or a line infiltration, etc.. I did a lit search afterwards and there was a case report on a pt with modafinil that was resistant to proprofol? She was pretty healthy so I'm not sure what else she could have been on that would cause propofol resistance or if there are certain genetic conditions that predispose? I don't expect to ever see that one again. I told her that if she ever had anesthesia in the future to make sure and inform them that she has a profound resistance to propofol. I should have saved the case to scour over any additional offending medications but I never was able to find much literature on "propofol resistance".

 

[Groove]

Yeah, all of our sedations in the ED are "deep". Most of these procedures just can't be completed otherwise. I don't know what the answer is regarding hospital credentialing but I don't think anesthesia should feel any sort of turf infringement. I mean, we can't do anything near what you guys can do. It's not like we're going to be requesting anesthesia machines and sevo anytime soon for the ED. You guys probably have no idea how frequently we are required to perform sedation in the ED. Trust me when I say you don't want to be consulted for this every time. It's a complete pain in the ass. That being said, I'd gladly give up all my "moderate sedation" privileges if anesthesia could be consulted to the ED for this kind of stuff 24/7/365. I hate doing sedation these days. It grinds things to a halt and locks me in a room for half an hour while anything could be coming through the ambulance bay.

 

[Groove]

What's equally egregious to me is that half the time we are expected to not only perform the sedation and monitor the pt but DO the actual procedure. It's absurd.

 

[DrDrummer]

I am credentialed for deep sedation at all the hospitals I work at. I have sat on sedation committees and reviewed cases. Most of the bad outcomes I have seen happened in GI or IR or the cath lab when anesthesia was not involved. And guess who bails them out at my current hospital when the patient has a respiratory arrest or needs to be intubated emergently? I have advocated for more anesthesia coverage for those cases (and for airway codes in these settings) but that ain't happening anytime soon, especially after hours.

I have never given a paralytic without placing an ETT or LMA and I think that would be outside the realm of what I feel comfortable with. I don't trust our RTs to bag a patient while I put in a hip and that would seem like a slamdunk lawsuit if there was a bad outcome. I have intubated people in order to facilitate getting procedures and diagnostic tests done, generally patients who were critically ill or profoundly altered and who were headed that way anyway due to AMS/agitation that was making it impossible or unsafe to accomplish said procedures. Wouldn't do that for a dislocation as at that point I want ortho involved anyway and they more more comfortable in the OR.

 

[Groove]

The stuff ortho expects us to sedate in the ED just royally pisses me off sometimes. 90yo granny with a broken humerus and wrist with afib, end stage COPD, CHF, on a gazillion meds with peri-arrest vitals who just ate McDonald's "Big Breakfast". One day the resident and attending were standing there and I was like "Guys....you've GOT to be kidding me. This lady is nowhere near getting sedated in the ED. Take that to the OR with an anesthesiologist." The attending looked super perturbed and I got a slight taste of the satisfaction anesthesia must get when they cancel a case. It's like the ultimate override.

 

[TooMuchResearch]

Bumping this thread to get some thoughts. Let’s say you have a hip dislocation. Patient absolutely needs sedation for reduction. After a total of 2.5 mg/kg of propofol patient still not sedated enough. You then add 1 mg/kg of ketamine. Still not sedated enough and reduction fails. At this point, you’re nervous to give more. Do you just admit the patient to have OR reduction with anesthesia or intubate the patient yourself and reduce? I’ve had this happen a few times. I always just admit and have it done in OR and after reviewing the chart anesthesia has always intubated the patient for reduction. The problem is ortho always gets upset and tells me “patient not sedated enough.” I frankly don’t have time to intubate a patient for a reduction and try to extubate in the ER.

We don't intubate for procedural sedation.
That said, I just keep bolusing propofol until it's the right dose.
For hips, that often means apnea.