Use of propofol sedation in the paediatric emergency department

Abstract

THE DILEMMAYour colleagues in the emergency department are very keento start using propofol for conscious sedation of childrenwho require reduction of fractures or other painful proce-dures in the emergency department. They have had goodexperience using this drug with adult patients and are com-fortable using it. When this is discussed at the pharmacyand therapeutics committee, one of the paediatric intensivecare physicians raises the issue of the safety of propofol forchildren. The chair of the committee would like your input.CHILDREN AND PAINFUL PROCEDURESThe management of acute pain and anxiety in childrenundergoing diagnostic or therapeutic procedures is anon-going challenge, especially in urgent care settings.Analgesia and sedation are increasingly being used toreduce the pain and anxiety associated with urgent andacute care of children (1). This raises new issues for clini-cians regarding the selection of the appropriate agent.PROPOFOLPropofol (2,6-diisopropylphenol) is a nonopioid, nonbarbi-turate, short-acting anesthetic agent that must be adminis-tered intravenously (2). Although originally confined tooperating rooms and intensive care units, propofol use isbecoming more popular in ambulatory care areas to facili-tate short procedures, because it has both the advantage ofrapid induction and recovery time.USE OF PROPOFOL IN CHILDRENIn the operating room, propofol has been used extensively forpaediatric anesthesia with a good track record in terms of effi-cacy and safety (3). The common adverse effects associatedwith propofol therapy include cardiopulmonary depression,upper airway obstruction, hypoventilation and apnea lead-ing to hypoxemia (in up to 10% of patients) (4-6).A recent major issue with respect to the use of propofolhas been the use of this drug for sedation of paediatricintensive care patients. This has been reinforced by a warn-ing from Health Canada that propofol use is contraindicat-ed for patients under 18 years of age in intensive care units(7). A potentially fatal complication known as ‘propofolinfusion syndrome’ has been described in critically ill chil-dren given long term propofol infusion, the syndrome beingcharacterized by the development of severe metabolic aci-dosis and rhabdomyolysis associated with hepatomegaly,lipemia, myocardial failure and hyperkalemia (7,8). Thissyndrome appears to occur primarily with long term propo-fol use in critically ill children who often have seriousunderlying pathology or are being treated with multipledrugs that may alter propofol metabolism, rather than withthe use of propofol for brief procedural sedation. Thus, theissues with which Health Canada is concerned regardingpropofol use in paediatric intensive care units are probablynot germane to the use of propofol in the emergencydepartment.However, there are other issues with respect to the use ofpropofol for procedural sedation. As propofol does not haveanalgesic properties, concurrent opioid therapy using agentssuch as fentanyl or morphine is common, but this can beassociated with an increased risk of respiration depressionand hypotension. Propofol can interact in a synergisticmanner with opioids as well as decrease elimination and dis-tribution clearance of opioids related to the metabolic alter-ation of opioid clearance. Hence, plasma concentration ofopioids (and opioid effects) can increase in the face of con-current therapy with propofol. As well, opioids maydecrease propofol elimination clearance.It should be remembered by all clinicians using propofolthat this agent was developed initially for use in the operat-ing room, and thus, patients undergoing sedation for diag-nostic or therapeutic procedures with propofol (or indeed,any conscious sedation) should be carefully monitored(9,10). Before proceeding, informed consent must beobtained and the clinician must ensure that the child hasfasted for an appropriate period of time. During the proce-dural sedation, basic monitoring should include continuousassessment of peripheral blood oxygen saturation, respiratoryrate and heart rate monitoring, with regular intermittentblood pressure measurement and assessment of depth ofsedation using an appropriate technique or scale. Expertpersonnel and facilities for securing and maintaining a