Brief ReportPropofol by infusion protocol for ED procedural sedation
Introduction
Sedation and analgesia are integral components in the care of critically ill or injured patients in the ED. Many painful and unpleasant procedures are more tolerable and easier to perform when effective sedation is used. Propofol is a sedative-hypnotic agent unrelated to benzodiazepines or barbiturates [1]. It is an induction agent commonly used by anesthesiologists and has recently been started to be used and studied for ED procedural sedation and analgesia (PSA). Propofol's short duration of action, metabolism, and ease of titration make it an excellent agent for ED procedures. Although the literature about its use in adults is not extensive, it has been associated with short recovery and total ED stay times, along with high patient satisfaction rates for patients undergoing painful procedures in the ED [2], [3], [4], [5], [6].
The effects of propofol usually begin within a minute and last less than 10 minutes after it is discontinued [1]. Propofol provides sedative and hypnotic properties at subanesthetic dosages, although it has no analgesic properties. Complications of propofol include dose-dependent respiratory depression and hypotension, which require close monitoring of the patient. Complications such as respiratory depression and hypotension seem to be similar to those of currently used medications for PSA [7]. Pain at the injection site is a commonly noted side effect of propofol, but nausea and vomiting are rare after its use [1]. There is no pharmacological antagonist for propofol.
The available literature regarding the safety and efficacy of propofol for ED PSA in adults is sparse, but growing. Several studies have been done using bolus-dosed propofol for pediatric ED patients and have shown it to be effective and safe for procedural sedation [8], [9], [10], [11]. Of the few studies evaluating propofol for ED PSA in adults, only 2 [2], [3] (with a total of 24 patients) used an infusion, rather than bolus, dosing. Infusions for loading and maintenance of anesthesia have been widely described in the anesthesia literature [12], [13] and would seem easily adaptable to PSA in the ED. A protocol for using infusion-dosed propofol was recently approved by our hospital administration as a choice for PSA in our institution. Our goal is to prospectively evaluate the complication rate and satisfaction among caregivers and patients while using this protocol in our ED.
Section snippets
Methods
A prospective, observational study of propofol for PSA in our ED was performed. Our ED sees approximately 35,000 patients per year and is part of a 420-bed tertiary care academic medical facility. The Institutional Review Board approval was obtained before initiating data collection. The use of propofol versus other medications for PSA was at the discretion of the attending physician in the ED at the time of patient presentation. Propofol was dosed by predetermined infusion protocol. This
Results
A total of 50 patients were enrolled in the study for 18 months (see Table 1). All of the patients who received propofol for PSA during that time were included. The median patient age was 42 years, and 64% were male. A variety of procedures were performed: 44% orthopedic manipulations, 34% incision and drainage of abscesses, 14% cardioversion, and 4% tube thoracostomy. All procedures were successfully completed. The average length of procedure was 14 minutes. Mean times for onset of sedation
Discussion
Propofol has specific pharmokinetics that make it very attractive for use in ED PSA. Specifically, its rapid onset and short duration of action make it an excellent choice for this purpose. However, its use is associated with the risks of respiratory depression and hypotension that require constant monitoring during its use.
Previous studies evaluating the use of propofol for ED PSA in adults have shown a high satisfaction rate despite a relatively high rate of adverse events. A recent study by
Limitations
The main limitations of our study were its observational nature and the relatively small number of patients studied. The lack of a concurrent control arm limits the use of our data for comparisons with other medications used for similar treatment. However, reports in the literature of other medications used for ED PSA may be used for comparisons. In addition, our main goal was to document complication and satisfaction rates of using propofol for procedural sedation rather than to compare agents.
Acknowledgments
The authors thank Carin Olson, MD, FACEP, for her help in reviewing this article.
References (16)
- et al.
Propofol for deep procedural sedation in the ED
Am J Emerg Med
(2005) - et al.
Propofol in emergency medicine: pushing the sedation frontier
Ann Emerg Med
(2003) - et al.
Propofol for procedural sedation in the pediatric emergency department
J Emerg Med
(2004) - et al.
Propofol for procedural sedation in children in the emergency department
Ann Emerg Med
(2003) - et al.
Propofol sedation by emergency physicians for elective pediatric outpatient procedures
Ann Emerg Med
(2003) - et al.
Propofol infusion for induction and maintenance of anesthesia in elderly patients: recovery and hemodynamic profiles
J Clin Anesth
(1996) - et al.
Pharmacology of emergency department pain management and conscious sedation
Emerg Med Clin North Am
(2000) - et al.
Propofol for conscious sedation: a case series
Acad Emerg Med
(1995)
Cited by (29)
Safety and efficacy of remimazolam in high risk colonoscopy: A randomized trial
2021, Digestive and Liver DiseaseCitation Excerpt :While propofol and midazolam are effective, each has disadvantages [3,4]. Propofol has excellent sedative properties [5], with a short half-life (t½) [6,7], allowing rapid recovery. Both propofol and its prodrug fospropofol [8], may cause respiratory depression, hypoxia, and hypotension [9], requiring continuous monitoring of vital signs and respiration.
Clinical Patterns of Continuous and Intermittent Palliative Sedation in Patients With Terminal Cancer: A Descriptive, Observational Study
2019, Journal of Pain and Symptom ManagementCitation Excerpt :However, the side effect of respiratory suppression is problematic. Frank LR et al. reported that eight of 50 patients experienced respiratory depression during procedural use of propofol.21 Another study reported the frequency of hypoxia with propofol use.
A phase IIb study comparing the safety and efficacy of remimazolam and midazolam in patients undergoing colonoscopy
2016, Gastrointestinal EndoscopyIs Propofol Safe If Given by Nonanesthesia Providers?
2013, Evidence-Based Practice of AnesthesiologyShould Propofol Be Given by Nonanesthesia Providers?
2009, Evidence-Based Practice of Anesthesiology
Preliminary results of this project were presented in abstract form at the American College of Emergency Physicians annual Scientific Assembly in Washington, DC, September 2005.
This project received no outside funding or support.