Administration of propofol for sedation of non-mechanically ventilated patients in non-critical care areas by anesthesia providers and non-anesthesia trained healthcare providers: a systematic review.

Abstract

The use of propofol as a sedative in various outpatient settings is controversial. At the heart of this controversy is the use of propofol by non-anesthesia trained healthcare providers. To synthesize the best available evidence on the administration of propofol for sedation by anesthesia and non-anesthesia providers in spontaneous breathing patients in non-critical care settings. This review considered non-anesthesia trained and anesthesia trained healthcare providers administering propofol as the agent for sedation in patients of all ages who were not mechanically ventilated and were undergoing procedures for gastrointestinal endoscopy, cardiac catheterization, and procedural sedation for emergency room and radiology procedures.This review included studies where propofol was the sole sedative agent used by non-anesthesia trained, and formally trained anesthesia healthcare providers.This review considered as outcomes procedure time, return to baseline functioning, postoperative recovery time, mean amount of propofol administered, patient satisfaction, incidence of adverse hemodynamic and respiratory events, unplanned admission to hospital, and death.This review considered randomized controlled trials, cohort studies, case-control studies, and case series/report studies. The search strategy aimed to find both published and unpublished studies in English language beginning with the commercial use of propofol in 1989 through 2011. Search was performed across: CINAHL, MEDLINE, Nursing@Ovid, EMBASE, Elsevier Science Direct, Mednar, and Proquest. Studies were critically appraised by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute. Data was extracted using the standardized data extraction tool from the Joanna Briggs Institute. Due to the heterogeneous nature of the interventions and outcome measurements, a meta-analysis was not possible; results are presented in a narrative summary. 9 studies were included in the review: 1 randomized controlled trial, 2 cohort studies, and 6 descriptive studies. In seven of the studies, non-anesthesia providers administered propofol, while two studies had anesthesia providers providing propofol sedation. Five studies reported procedure time. None of the studies reported a return to baseline functioning. Four studies reported postoperative recovery time. One study reported mean propofol dosage according to the two phases of the study, while another study in addition to reporting total and mean propofol dosages, differentiated propofol dosage according to ASA classification. Six of the studies reported average or mean propofol dosage, with one study also reporting the propofol induction dosage. Reporting of adverse hemodynamic and respiratory events varied in the studies. None of the studies reported unplanned admission to the hospital or death. The evidence suggests that anesthesia healthcare providers have the experience and training to safely administer propofol in non-critical care settings involving procedures in non-mechanically ventilated patients. The evidence also suggests that non-anesthesia trained healthcare providers can safely administer propofol sedation in low-risk patients who are not mechanically ventilated if they have received specialized training in the use of propofol sedation, are experienced in its administration, and follow a defined dosage protocol. The administration of propofol sedation by anesthesia providers can be safely administered in patients of all risk categories and depth of sedation.The administration of propofol sedation by non-anesthesia providers can be safely administered to low risk patients for moderate sedation providing the non-anesthesia provider is specially trained and experienced in the administration of propofol sedation while using a defined dosage protocol. Randomized controlled trials are needed to examine the propofol sedation by non-anesthesia healthcare providers in spontaneous breathing patients in non-critical care settings. The type of training required for safe administration of propofol in the outpatient settings should be explored.