Pain ManagementPropofol sedation by emergency physicians for elective pediatric outpatient procedures☆
Introduction
Many children have chronic illnesses requiring frequent procedures for diagnosis and management.1 These procedures may be brief but are often painful and anxiety provoking. Sedatives are necessary routinely in the outpatient setting for these children requiring painful diagnostic and therapeutic interventions. Statements supporting the appropriate use of sedative agents for pain management in children have been issued by the American Academy of Pediatrics in conjunction with the American Society of Anesthesiologists (ASA)2 and the American College of Emergency Physicians.3 Appropriate pain management is now considered standard of care for the emergency physician.4, 5, 6 Increasing numbers of painful pediatric medical procedures are being performed on an outpatient basis. Current opinion suggests that further study of some of the ultrashort-acting agents for use in the outpatient setting is advisable.7
The ideal agent for such sedations is safe and easy to administer, with rapid onset of action and easily controlled levels of sedation. It should allow rapid recovery with minimal adverse effects. Many of the sedation agents currently in use have the significant disadvantage of prolonged sedation.7, 8, 9, 10, 11, 12, 13, 14 A significant disadvantage of 2 commonly used emergency department (ED) sedative regimens, midazolam/fentanyl and ketamine, is that both regimens frequently require 1 hour or more for recovery.7, 12, 13, 14 In contrast, children typically have recovered approximately 15 minutes after discontinuation of the ultrashort-acting sedative propofol.15
Propofol is a powerful sedative, characterized by rapid onset and short duration of action.16 Propofol controls stress responses and has anticonvulsant and amnestic properties.17, 18 It does not itself have analgesic properties but may be used in combination with opioids.17, 18 These characteristics make propofol an attractive medication choice to facilitate short, painful procedures. Propofol adverse effects include transient hypotension and dose-dependant respiratory depression.19, 20, 21
Propofol's versatility as a sedative agent has resulted in its increasing use to facilitate minor procedures outside of the operating room setting. Propofol sedation has been studied for elective oncology procedures22, 23 and has been recommended for endoscopic retrograde cholangiopancreatography,24 dermatologic procedures,25 and magnetic resonance imaging.26, 27 Madan et al28 describe propofol as a feasible option for pediatric diagnostic ophthalmic procedures. Similarly, Elitsur et al29 have documented the use of propofol in 104 children undergoing pediatric gastrointestinal endoscopic procedures. A role is also seen for this agent in dentistry.30
Three prospective studies of propofol sedation in the ED suggest it may be safely administered by emergency physicians for short painful procedures in adult31 and pediatric patient populations.15, 32 Although these were small case series, propofol was found to be a sedative agent with predictable efficacy, high patient satisfaction, and adverse effects that could be readily and safely managed by emergency physicians. There was no morbidity or mortality associated with short-term propofol use.
The objective of this study is to describe the efficacy and adverse effects of propofol sedation in a large case series administered by pediatric emergency physicians to facilitate outpatient pediatric procedures.
Section snippets
Theoretical model of the problem
Brief and painful procedures are performed in the outpatient setting, requiring sedation provided by the emergency physician. Propofol is an ideal sedative agent, with rapid onset of action and rapid recovery.16 However, safety and efficacy when propofol is administered by emergency physicians has been inadequately studied.15, 31, 32 Documentation of adverse effects, in particular, respiratory depression and hemodynamic instability, is warranted in this setting. In addition, documentation of
Characteristics of study patients
Thirteen pediatric emergency physicians administered propofol to 87 patients during the 9-month study period. Each patient received propofol once (n=41), twice (n=15), 3 times (n=3), 4 times (n=6), 5 times (n=5), 6 times (n=7), 8 times (n=1), 9 times (n=1), 10 times (n=1), 12 times (n=2), 13 times (n=3), or 15 times (n=2), for a total of 291 discrete sedation events for 550 procedures. Table 1 shows patient demographic characteristics.
Two or more procedures were performed in 263 (91%) of the
Limitations
There were several limitations to this study. First, the level of sedation was not objectively scored in this study, making it difficult to quantify sedation depth. Objective measures of sedation depth may give more detailed information about safety and efficacy. Second, multiple physicians administered the propofol medication. Each physician may have had a different threshold for patient movement during the procedure, affecting the mean and median doses of propofol, which, however, may better
Discussion
Our data suggest that propofol, when administered by emergency physicians under the guidance of a sedation protocol, provides safe and effective sedation for short painful procedures in the outpatient setting. Although transient cardiopulmonary depression from propofol was not infrequent, all adverse events in this study were promptly identified and easily managed by pediatric emergency physicians. The ultrashort-acting attribute of propofol permitted continual titration to effect and prompt
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Cited by (104)
Anesthesia Delivery in the MRI Environment
2020, Anesthesia Equipment: Principles and ApplicationsClinical Practice Guideline for Emergency Department Procedural Sedation With Propofol: 2018 Update
2019, Annals of Emergency MedicineEvaluation of methohexital as an alternative to propofol in a high volume outpatient pediatric sedation service
2017, American Journal of Emergency MedicineCharacteristics of and Predictors for Apnea and Clinical Interventions During Procedural Sedation
2016, Annals of Emergency MedicineCitation Excerpt :For example, when a pattern of etco2 of less than 30 or greater than 50 mm Hg occurs during propofol sedation, especially in older patients, clinicians should be mindful of the higher risk of apnea within the next 30 to 90 seconds of this occurrence and adjust drug titration, patient stimulation level, and clinical vigilance accordingly. Previous studies in ED procedural sedation have primarily focused on safety by determining the type and frequency of adverse events in general15,16 and for individual sedation agents and regimens.17-24 These studies used empirically derived, nontemporal ventilatory parameters (etco2 greater than 50 mm Hg, a 10% absolute change from baseline, or loss of carbon dioxide waveform, termed subclinical respiratory depression) to determine the incidence of respiratory depression and to describe the relationship between respiratory depression, hypoxia, and clinical interventions.3-9,25
Anesthesia and Sedation for Pediatric Procedures Outside the Operating Room
2016, Smith's Anesthesia for Infants and Children, Ninth EditionUse of ambulatory anesthesia with manually assisted ventilation for tympanic membrane regeneration therapy in children
2015, American Journal of Otolaryngology - Head and Neck Medicine and Surgery
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Author contributions: EG, KEB, and DSN conceived the study. The study was designed by EG, HAK, and EPJ. EG, EPJ, HAK, KEB, and DSN all undertook recruitment of patients. EG, EPJ, and HAK supervised the conduct of the trial and data collection. EG, CP, and EPJ drafted the manuscript, and all authors contributed substantially to its revision. EG takes responsibility for the paper as a whole.
Presented as a poster at the Ambulatory Pediatric Association/Society for Pediatric Research national meeting, Baltimore, MD, May 2001.
The authors report this study did not receive any outside funding or support.
Reprints not available from the authors.