Propofol Overview

     An elderly man with known COPD was admitted to the hospital with severe shortness of breath. He failed to improve after two weeks despite use of high dose prednisone and antibiotics. The patient complained of abdominal pain and eventually found to have air under his diaphragm. A CT scan revealed an abscess, most likely diverticular, and the radiologist placed a drain in the abscess. After two or three days the drain fell out. On Tuesday, two days later he had an acute abdomen and surgeons decided to operate. Initially, the family was reluctant to proceed with the surgery but after hearing the patient was willing, agreed. The surgery was performed. Post-op, he recovered fairly well and was extubated on day 2 following surgery. On Friday, post op day 4, the patient looked good.

     On Sunday, the nurse caring for the patient saw a change for the worse has occurred. The patient could not get comfortable and said he was dying. A daughter was distressed by her father’s discomfort. The housestaff ordered sequentially lorazepam, morphine, haldol, and toradol. None was effective. He seemed confused. In response to the physician query, "Are you in pain?" the patient stated he was not. The nurse finished her shift and transferred care to a nurse who will care for him for two hours until the next usual shift happens. Distressed by his continuing agony, the family turned to this nurse for action. She called the Chief Vascular Resident, whom she respected and trusted would find a solution. In doing so, she bypassed the standard protocol of discussing this with the residents. The CVR decides to put him on a low dose propofol drip with the understanding that she will be available to intubate him if he gets in trouble. Propofol is an anesthesia drug which has been used in ICUs at other institutions to relieve agitation. In fact, a patient at this hospital received it earlier in the year although it was not part of the formulary; the staff knew he had been successful with the drug at another hospital. The nurse ordered the propofol verbally and started the drip. The patient became calm yet arousable and confused.

     In order to keep him calm during Sunday night, the propofol drip was increased to anesthetic levels. On Monday morning, the staff immediately identified that the patient was much sicker and required a repeat operation. The charge nurse discovered the patient has been placed on propofol and believing it to be unsafe was very concerned. She contacted the Nurse Manager who notified the Risk Manager of a near miss. The charge nurse discussed the matter with the nurses who managed the drip, indicating they were operating outside their license because propofol is an anesthetic drug, therefore requiring an anesthesiologist. The nurses wondered how they should know that this drug was not allowed in the ICU since there was no policy regarding it. The charge nurse replied that there is the expectation that every drug administered in the ICU should be completely understood to the extent of the manufacturer’s recommendations for administration. No official discipline action for the nurses involved occurred.