Iv sedation during diagnostic and therapeutic procedures

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Appendix B
I. Statement of principle

This section of the Intravenous Sedation policy addresses, specifically, the use of propofol for sedation. The purposeful use of propofol for anesthesia is addressed in the Policy and Procedures manual of the Department of Anesthesiology.

The pharmacokinetic and phamacodynamic properties of propofol make this agent the most ideal sedative agent available today. Its efficacy has no peer, it is very short acting, and it has highly desirable antiemetic and pro-euphoric side effects. In fact, in many clinical circumstances, the use of alternative agents (e.g. midazolam) is distinctly inferior. However, propofol is highly potent, and causes significant respiratory and hemodynamic depression (including apnea, severe hypotension, and even cardiovascular collapse).

In view of the above, it is clear that the use of propofol for conscious and deep sedation is highly desirable, and beneficial to patients, when circumstances permit (see below). However, its potency and severe respiratory and hemodynamic depression mandate that it be restricted to use by or on the order of clinicians trained in its use, and independently capable of managing the latter severe consequences.

II. Use

A. Staff restrictions

Propofol is restricted to use by, or on the order of “approved Physicians”. These are defined as:

1. a member of the clinical staff of the Department of Anesthesiology, or,

2. physicians Board certified in Critical Care Medicine.

There are no exceptions to this restriction.

B. Restrictions on circumstances of use

1. The appropriate clinical use of propofol (as determined by the approved clinician) is not restricted to any particular location in or outside the Hospital grounds.

  1. The administration of propofol within the context of this policy requires one of the following, with no exceptions:

i. the immediate presence, at the patient’s bedside, of the approved clinician, or

ii. the administration of propofol to a patient under the direct verbal order of an approved clinician, with a surrogate physician at the bedside, aided by a nurse specifically trained in the administration of deep sedation, or

iii. the administration of propofol to an endotracheally intubated patient in the ICU, Radiology suite, or Emergency Department, under the direct verbal order of an approved clinician to a surrogate physician at the bedside.
C. Dosage

Propofol is most commonly used undiluted, i.e. 10 mg/ml. Dosing is dependent on purpose of use, duration of use, the patient’s medical condition, and other agents used concurrently, per the judgment of the approved clinician. For sedation of adults by infusion, dosing usually ranges 1-6 mg/kg/hr*. For sedation by intermittent boluses, bolus doses usually range from 0.3-0.8 mg/kg*.
*lean body weight

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