Brief Report
Propofol by infusion protocol for ED procedural sedation

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Abstract

Introduction

Propofol is an effective agent for use in procedural sedation and analgesia (PSA). Most ED studies have used a bolus-dosed protocol. We evaluated the efficacy, complication rate, and satisfaction among caregivers and patients while using an infusion-dosed protocol of propofol for PSA in our ED.

Methods

A prospective, observational study was performed in our academic ED. Propofol use was at the discretion of the ordering physician and dosed by predetermined infusion protocol. Variables measured included adverse events, times of sedation, procedure, and recovery. Patient and provider satisfaction were measured using a 10-cm visual analog scale.

Results

Fifty patients were enrolled over 18 months. Procedures were varied, and all were successfully completed. The mean propofol dose was 174 mg (SD = 164 mg). Average times to sedation (4.6 minutes, SD = 2.6 minutes) and recovery (8.2 minutes, SD = 5.8 minutes) were short. Complications included 8 patients with respiratory depression and 6 with hypotension, all easily reversible. Satisfaction scores were uniformly high. Only 34% of patients had any memory of the procedure, and 94% would agree to use it again if necessary.

Conclusions

Infusion-dosed propofol is effective for ED PSA. Total doses, effectiveness, satisfaction rates, and complications of infusion-dosed propofol are comparable to findings from studies using bolus-dosed protocols.

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)

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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.

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