Propofol sedation by emergency physicians for elective pediatric outpatient procedures

Abstract

Study objective

We describe the efficacy of propofol sedation administered by pediatric emergency physicians to facilitate painful outpatient procedures.

Methods

By using a protocol for patients receiving propofol sedation in an emergency department–affiliated short-stay unit, a prospective, consecutive case series was performed from January to September 2000. Patients were prescheduled, underwent a medical evaluation, and met fasting requirements. A sedation team was present throughout the procedure. All patients received supplemental oxygen. Sedation depth and vital signs were monitored while propofol was manually titrated to the desired level of sedation.

Results

There were 291 separate sedation events in 87 patients. No patient had more than 1 sedation event per day. Median patient age was 6 years; 57% were male patients and 72% were oncology patients. Many children required more than 1 procedure per encounter. Most commonly performed procedures included lumbar puncture (43%), intrathecal chemotherapy administration (31%), bone marrow aspiration (19%), and bone biopsy (3%). Median total propofol dose was 3.5 mg/kg. Median systolic and diastolic blood pressures were lowered 22 mm Hg (range 0 to 65 mm Hg) and 21 mm Hg (range 0 to 62 mm Hg), respectively. Partial airway obstruction requiring brief jaw-thrust maneuver was noted for 4% of patient sedations, whereas transient apnea requiring bag-valve-mask ventilation occurred in 1% of patient sedations. All procedures were successfully completed. Median procedure duration was 13 minutes, median sedation duration was 22 minutes, and median total time in the short stay unit was 40 minutes.

Conclusion

Propofol sedation administered by emergency physicians safely facilitated short painful procedures in children under conditions studied, with rapid recovery.

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.