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PED-EM-L  October 2013

PED-EM-L October 2013

Subject:

Re: Propofol for migraines

From:

"Chavda, Kamal" <[log in to unmask]>

Reply-To:

Chavda, Kamal

Date:

Thu, 31 Oct 2013 16:36:52 +0000

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (160 lines)

Hi
For those who use propfol for migraine in the ED-- Does NPO status matter? With nausea / vomiting associated with migraines- would using a sedation medication without adequate  NPO time be a risk for aspiration??

Thanks

Kamal K Chavda, MD

________________________________________
From: Pediatric Emergency Medicine Discussion List [[log in to unmask]] on behalf of Baxter, Amy [[log in to unmask]]
Sent: Thursday, October 31, 2013 11:35 AM
To: [log in to unmask]
Subject: Re: Propofol for migraines

The size of the vein matters; if it's antecubital propofol stings less than
a hand IV.

To make a mini-bier block for our propofol MRI and CT sedations, we studied
1mg/kg up to 25mg lidocaine (2.5cc with usual formulation) IV with
tourniquet in place.  Pushing the lido slowly over one minute rather than
bolusing and waiting one minute resulted in lower pain but the difference
was not significant.  It was significantly better than previously reported
propofol alone pain using the same metric.

I know of at least two anesthesiologists using Buzzy to help the burning of
infusion for propofol, but no RCT's yet.

Thanks for bringing up the concept - don't suppose anyone has guidelines
for migraines/propofol?


On Wed, Oct 30, 2013 at 11:09 PM, Mike Falk <[log in to unmask]> wrote:

> Two questions.  First, how do you get past the "propofol" phobia and use
> this in the ED but not as procedural sedation?  Second, propofol can be
> very painful when administer peripherally?  Do you use some lido?
> Mike Falk
>
> Sent from my iPhone
>
> > On Oct 30, 2013, at 7:44 PM, "Meckler, Garth" <[log in to unmask]>
> wrote:
> >
> > Hey Pam, we published a case-control series of low-dose propofol for
> pediatric migraine (in PEC) - the idea came from two large series in adults
> with chronic headache.
> > We are currently starting to enroll for a prospective RCT based on our
> small series and review of the adult literature.
> >
> > No one knows for sure in children what dose might be effective.  In
> adults, 10-20 mg IV bolus was used, repeated every 10 minutes until pain
> free (usually 2-3 doses required).  At this dose, no patient fell asleep
> and there were no complications.
> > We extrapolated from these data and chose a sub-anesthetic dose of
> 0.3-0.5 mg/kg IV push.  In our series, no patient fell asleep or had any
> abnormalities of BP or POX, though we monitored according to sedation
> guidelines.
> > Our study was small and non-randomized, so no definitive evidence exists
> for this treatment modality, hence the RCT....anecdotally, I can share our
> approach was to give IV bolus doses separated by about 10 minutes (repeat
> dosing based on VAS pain score and complete absence of objective or
> subjective drug effect between doses); we had excellent success even among
> those who had failed all other standard therapies for migraine.  Those who
> responded did so immediately - the typical progression was 10/10 pain
> before treatment, 8/10 after one bolus, 4/10 after a second and 0/10 after
> a third.  We do not know the rates of recurrence, but they are high with
> current standard treatment options including triptans and dopamine
> antagonists.
> >
> > Happy to send copies of the article or the references from the adult
> literature upon request.
> >
> > Garth Meckler, MD, MSHS
> > BC Children's Hospital / University of British Columbia
> >
> >
> >> On Oct 30, 2013, at 4:31 PM, Pamela MURPHY <[log in to unmask]>
> wrote:
> >>
> >> I had an interesting case last week of a 15yo male presenting with
> headache and altered level of consciousness with combativeness.  He had no
> fever, no trauma and no history of migraines although family history was
> positive for migraines.  Workup, including drug screen and CT of head, was
> negative.  In plans for admission and eval by peds neuro I did an LP with
> propofol sedation thinking about an article I had seen recently on propofol
> for migraines.  Amazingly, the teen "woke up" and was perfectly normal post
> sedation.  He was admitted for observation and peds neuro eval and was
> discharged with a diagnosis of complex migraine.
> >>
> >> So, this raises a few questions.
> >>
> >> Are you using propofol in the ED for migraines?
> >> If so, first line or after traditional treatment failure?
> >> What dose do you use?
> >>
> >> Thanks for input!
> >>
> >> Pam Murphy
> >>
> >>
> >>
> >>
> >> Pamela S Murphy, MD
> >> Mendy's Place
> >> John C. Lincoln Deer Valley Hospital
> >>
> >>
> >>
> >>
> >>
> >>
> >>
> >> For more information, send mail to [log in to unmask] with
> the message: info PED-EM-L
> >> The URL for the PED-EM-L Web Page is:
> >>                http://listserv.brown.edu/ped-em-l.html
> >
> > For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> > The URL for the PED-EM-L Web Page is:
> >                 http://listserv.brown.edu/ped-em-l.html
>
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                  http://listserv.brown.edu/ped-em-l.html
>



--
Amy Baxter MD FAAP FACEP
Director of Emergency Research, Scottish Rite
Children's Healthcare of Atlanta

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