So I went up to the ICU to do an EGD on an upper GI bleed yesterday. The patient was actually stable, no real reason for her to be there. 5'4" 112kg (kind of weird...she told me she weighed 136 lbs), HTN, DM, fibromyalgia/chronic pain (seeing pain doc), CAD. She had a really bad outbreak of shingles on her face and had taken a ton of ibuprofen and had caused a bleed.

She had a protonix drop at 8mg/hour, NS at 100ml/hour through a femoral cvc, along with PRN morphine and zofran. While I'm interviewing her lab comes in and the nurse draws of a CBC on her that the intensivist wanted.

I don't give narcotics or versed for my endos, just straight propofol. I turn the fluids up to 500ml an hour for the case, give her 120mg through the cvc. Immediately she yells. Weird, propofol burns but not through a central line. I draw back on it, see blood return in the line, flush it. I figure she's just being a little dramatic. She's getting a little sleepy but nowhere near out and it's taking a while, so I give another 80mg and she yells again.

Now I know something is up, but there's clearly blood return. I have the nurse grab a pressure line to transduce it while I hook up an empty syringe...sure enough it starts filling by itself.

Meanwhile, she's finally drifted off (took quite a while....easy to see why in retrospect), and the GI guy has started the endo. I tell him I think the line is arterial, and I stop all the infusions.

We hook up the transducer, and get an arterial waveform.

She stays out for the rest of the scope, which is pretty quick. Good DP and PT pulses, no change in cap refill on that leg. I have the nurse call the intensivist, who orders it DC'd.

Apparently an ER attending put it in because of poor vascular access, so I went down to them and let them know. He used the ultrasound.

I followed up with her today and she's fine, no sequelae, which is in line with the few case studies I was able to find online, all of which say propofol is harmless intra-arterially. A rat study done in the 90's showed no endothelial damage.

Anyways, kind of cool. I'm thinking about writing it up.