Propofol For Procedural Sedation Research Articles

The Utility of High-Flow Oxygen During Emergency Department Procedural Sedation and Analgesia With Propofol: A Randomized, Controlled Trial

We determine whether high-flow oxygen reduces the incidence of hypoxia by 20% in adults receiving propofol for emergency department (ED) sedation compared with room air. We randomized adults to receive 100% oxygen or compressed air at 15 L/minute by nonrebreather mask for 5 minutes before and during propofol procedural sedation. We administered 1.0 mg/kg of propofol, followed by 0.5 mg/kg boluses until the patient was adequately sedated. Physicians and patients were blinded to the gas used. Hypoxia was defined a priori as an oxygen saturation less than 93%; respiratory depression was defined as an end tidal CO(2) greater than 50 mm Hg, a 10% absolute change from baseline, or loss of waveform. We noted significantly less hypoxia in the 59 patients receiving high-flow oxygen compared with the 58 receiving compressed air (19% versus 41%; P=.007; difference 23%; 95% confidence interval 6% to 38%). Respiratory depression was similar between groups (51% versus 48%; difference 2%; 95% confidence interval -15% to 22%). We observed 2 adverse events in the high-flow group (1 hypotension, 1 bradycardia) and 2 in the compressed air group (1 assisted ventilation, 1 hypotension). High-flow oxygen reduces the frequency of hypoxia during ED propofol sedation in adults.

Randomized Clinical Trial of Propofol With and Without Alfentanil for Deep Procedural Sedation in the Emergency Department

The objectives were to compare the efficacy, occurrence of adverse events, and recovery duration of propofol with and without alfentanil for use in procedural sedation in the emergency department (ED). This was a randomized nonblinded prospective trial of adult patients undergoing procedural sedation for painful procedures in the ED. Patients with pain before the procedure were given intravenous (IV) morphine sulfate until their pain was adequately treated at least 20 minutes before starting the procedure. Patients received 1 mg/kg propofol either with or without a supplemental dose of 10 mug/kg alfentanil for deep procedural sedation. Doses, vital signs, nasal end-tidal CO(2) (ETCO(2)), pulse oximetry, and bispectral electroencephalographic (EEG) analysis scores were recorded. Subclinical respiratory depression was defined as a change in ETCO(2) of >10 mmHg, an oxygen saturation of <92% at any time, or an absent ETCO(2) waveform at any time. Clinical events related to respiratory depression were noted during the procedure, including the addition of or increase in the flow rate of supplemental oxygen, the use of a bag-valve mask apparatus, airway repositioning, or stimulation to induce breathing. After the procedure, patients were asked if they experienced pain during the procedure or had recall of the procedure. A total of 150 patients were enrolled; 146 underwent sedation and were included in the analysis. Seventy-four patients received propofol, and 71 received propofol with alfentanil. No clinically significant complications were noted. Subclinical respiratory depression was seen in 24/74 patients in the propofol group and 30/71 patients in the propofol/alfentanil group (effect size = 9.8%, 95% CI = -5.8% to 25.5%). Clinical signs of respiratory depression included an increase in supplemental oxygen use in 25 of the 74 propofol patients and 31 of the 71 propofol/alfentanil patients (effect size 9.9%, 95% CI = -5.9% to 25.7%), the use of bag-valve mask apparatus in seven patients in the propofol group and 12 in the propofol/alfentanil group (effect size = 5.6%, 95% CI = -3.5% to 18.4%), airway repositioning in 13 propofol patients and 20 propofol/alfentanil patients (effect size = 10.6%, 95% CI = -3.0% to 24.2%), and stimulation to induce breathing in 11 propofol patients and 20 propofol/alfentanil patients (effect size = 13.3%, 95% CI = 0.1% to 26.5%). The total time of the procedure was longer for the alfentanil/propofol group (median = 11 minutes, range = 5-22 minutes) than for the propofol group (median = 9 minutes, range = 1 to 43 minutes; effect size = 1.93 minutes, 95% CI = 0.73 to 2.58, p = 0.02). Pain during the procedure was reported by 10 of the 74 patients in the propofol group and 7 of the 71 patients in the propofol/alfentanil group (effect size = 4.5%, 95% CI = -6.8% to 14.1%). Recall of some part of the procedure was reported by 12 patients in the propofol group and 9 in the propofol/alfentanil group (effect size = 3.5%, 95% CI = -7.9% to 15.0%). All procedures were successfully completed. The use of supplemental alfentanil with propofol for procedural sedation did not result in a difference in reported pain or recall immediately after the procedure. There was an increase in the proportion of patients who required stimulation to induce respiration during the procedure in patients who received propofol with supplemental alfentanil. The addition of supplemental opioid to procedural sedation with propofol does not appear beneficial.

Subdissociative‐dose Ketamine versus Fentanyl for Analgesia during Propofol Procedural Sedation: A Randomized Clinical Trial

The authors sought to compare the safety and efficacy of subdissociative-dose ketamine versus fentanyl as adjunct analgesics for emergency department (ED) procedural sedation and analgesia (PSA) with propofol. This double-blind, randomized trial enrolled American Society of Anesthesiology (ASA) Class I or II ED patients, aged 14-65 years, requiring PSA for orthopedic reduction or abscess drainage. Subjects received 0.3 mg/kg ketamine or 1.5 mug/kg fentanyl intravenously (IV), followed by IV propofol titrated to deep sedation. Supplemental oxygen was not routinely administered. The primary outcomes were the frequency and severity of cardiorespiratory events and interventions, rated using a composite intrasedation event rating scale. Secondary outcomes included the frequency of specific scale component events, propofol doses required to achieve and maintain sedation, times to sedation and recovery, and physician and patient satisfaction. Sixty-three patients were enrolled. Of patients who received fentanyl, 26/31 (83.9%) had an intrasedation event versus 15/32 (46.9%) of those who received ketamine. Events prospectively rated as moderate or severe were seen in 16/31 (51.6%) of fentanyl subjects versus 7/32 (21.9%) of ketamine subjects. Patients receiving fentanyl had 5.1 (95% confidence interval [CI] = 1.9 to 13.6; p < 0.001) times the odds of having a more serious intrasedation event rating than patients receiving ketamine. There were no significant differences in secondary outcomes, apart from higher propofol doses in the ketamine arm. Subdissociative-dose ketamine is safer than fentanyl for ED PSA with propofol and appears to have similar efficacy.

A Cost‐effectiveness Analysis of Propofol versus Midazolam for Procedural Sedation in the Emergency Department

To determine the incremental cost-effectiveness of using propofol versus midazolam for procedural sedation (PS) in adults in the emergency department (ED). The authors conducted a cost-effectiveness analysis from the perspective of the health care provider. The primary outcome was the incremental cost (or savings) to achieve one additional successful sedation with propofol compared to midazolam. A decision model was developed in which the clinical effectiveness and cost of a PS strategy using either agent was estimated. The authors derived estimates of clinical effectiveness and risk of adverse events (AEs) from a systematic review. The cost of each clinical outcome was determined by incorporating the baseline cost of the ED visit, the cost of the drug, the cost of labor of physicians and nurses, the cost and probability of an AE, and the cost and probability of a PS failure. A standard meta-analytic technique was used to calculate the weighted mean difference in recovery times and obtain mean drug doses from patient-level data from a randomized controlled trial. Probabilistic sensitivity analyses were conducted to examine the uncertainty around the estimated incremental cost-effectiveness ratio using Monte Carlo simulation. Choosing a sedation strategy with propofol resulted in average savings of $17.33 (95% confidence interval [CI] = $24.13 to $10.44) per sedation performed. This resulted in an incremental cost-effectiveness ratio of -$597.03 (95% credibility interval -$6,434.03 to $6,113.57) indicating savings of $597.03 per additional successful sedation performed with propofol. This result was driven by shorter recovery times and was robust to all sensitivity analyses performed. These results indicate that using propofol for PS in the ED is a cost-saving strategy.

Propofol for ED Procedural Sedation — How Good Is It?

Propofol, an ultra–short-acting sedation agent that might cause hypotension and transient apnea, is becoming increasingly popular for procedural sedation. Canadian researchers prospectively evaluated efficacy, safety, and patient satisfaction in 113 patients (mean age, 50; 62% male) who received propofol for procedural sedation in the emergency department during a 2-year period. The procedures included orthopedic reductions (44%), cardioversion (37%), and abscess incision and drainage …

Combination Ketamine and Propofol for Procedural Sedation and Analgesia

The combination of ketamine and propofol for procedural sedation and analgesia theoretically may be beneficial, with the rationale being that using lower doses of each agent may result in a reduction of the undesirable adverse effects of both agents while maintaining optimal conditions for performing procedures. To examine the current evidence for the efficacy and safety of ketamine and propofol in combination for procedural sedation and analgesia, we searched the MEDLINE (1966-March 2007), EMBASE (1980-March 2007), and Cochrane Database of Systematic Reviews (through the first quarter of 2007) databases for reports describing the use of ketamine and propofol in combination for procedural sedation and analgesia. Additional published reports were identified through a manual search of references from retrieved articles. Prospective, comparative, full-text reports of studies performed in humans that were published in English were reviewed for inclusion. Both authors independently evaluated all studies. Studies in adult and pediatric patients were included if they evaluated efficacy or safety end points. Eight clinical trials were included, seven of which compared a combination of propofol and ketamine with propofol monotherapy. In these trials, variable milligram:milligram ratios of propofol and ketamine were used, ranging from 10:1-2:1, and the optimum dose of these agents in combination is unclear. Combination propofol and ketamine has not demonstrated superior clinical efficacy compared with propofol alone for procedural sedation and analgesia. Conflicting data exist regarding reduced hemodynamic and respiratory complications in patients receiving the combination compared with propofol monotherapy. At higher doses, the addition of ketamine to propofol may incur more adverse effects. Compatibility data for the two agents combined in a syringe are limited. The available evidence does not support the use of a fixed-dose ketamine-propofol combination for procedural sedation and analgesia. Further research is needed to elucidate the role, if any, of this combination for procedural sedation and analgesia.

391: Propofol for Procedural Sedation in a Rural Emergency Department

391: Propofol for Procedural Sedation in a Rural Emergency Department

Propofol for procedural sedation in the emergency department

Objectives: To observe procedural sedation practice within a district general hospital emergency department (ED) that uses propofol for procedural sedation. Methods: Prospective observation of procedural sedation over an 11 month...

Propofol for Emergency Department Procedural Sedation and Analgesia: A Tale of Three Centers

To characterize propofol procedural sedation and analgesia (PSA) encounters for a large patient population at multiple emergency department (ED) sites. The authors sought to assess the frequency of respiratory and cardiovascular events during propofol PSA within these settings. This study was a prospective, descriptive series of a consecutive sample of ED patients receiving propofol for PSA at three study sites. Patients were monitored for PSA-related events, including predefined clinically relevant cardiovascular and respiratory events. Data collection was performed during PSA with a standardized data collection sheet unique to each site. Propofol was administered during PSA to 792 patients during the respective reporting period at each center. Indications for sedation included dislocation reduction (38%), cardioversion (10%), fracture reduction (35%), abscess incision and drainage (8%), computed tomography imaging (2%), and tube thoracostomy (1%). The cumulative rate of oxygen desaturation events for all study sites was 7.7% with a brief period of assisted ventilation with bag-valve mask in 3.9%. The cumulative rate of PSA-related hypotensive events was 3.5%. Increasing patient age and specific clinical procedure were clinical variables most associated with any propofol-related respiratory event. All PSA-related events resolved with supportive interventions during the PSA encounter. No patients required endotracheal intubation, prolonged observation, or admission for PSA-related complications. Propofol typically confers a deep sedation experience for ED PSA. The most common PSA events associated with propofol are respiratory related and appear consistent across these three practice settings. All propofol-related PSA events resolved with brief supportive interventions in the ED with no adverse sequelae.

Propofol for Emergency Department Procedural Sedation and Analgesia: A Tale of Three Centers

Objectives: To characterize propofol procedural sedation and analgesia (PSA) encounters for a large patient population at multiple emergency department (ED) sites. The authors sought to assess the frequency of respiratory and cardiovascular events during propofol PSA within these settings. Methods: This study was a prospective, descriptive series of a consecutive sample of ED patients receiving propofol for PSA at three study sites. Patients were monitored for PSA-related events, including predefined clinically relevant cardiovascular and respiratory events. Data collection was performed during PSA with a standardized data collection sheet unique to each site. Results: Propofol was administered during PSA to 792 patients during the respective reporting period at each center. Indications for sedation included dislocation reduction (38%), cardioversion (10%), fracture reduction (35%), abscess incision and drainage (8%), computed tomography imaging (2%), and tube thoracostomy (1%). The cumulative rate of oxygen desaturation events for all study sites was 7.7% with a brief period of assisted ventilation with bag-valve mask in 3.9%. The cumulative rate of PSA-related hypotensive events was 3.5%. Increasing patient age and specific clinical procedure were clinical variables most associated with any propofol-related respiratory event. All PSA-related events resolved with supportive interventions during the PSA encounter. No patients required endotracheal intubation, prolonged observation, or admission for PSA-related complications. Conclusions: Propofol typically confers a deep sedation experience for ED PSA. The most common PSA events associated with propofol are respiratory related and appear consistent across these three practice settings. All propofol-related PSA events resolved with brief supportive interventions in the ED with no adverse sequelae.

Propofol for Procedural Sedation: One Versus Two Physicians

Propofol for Procedural Sedation: One Versus Two Physicians

Randomized Clinical Trial of Etomidate Vs. Propofol for Procedural Sedation During Fracture and Dislocation Reduction in the Emergency Department

Randomized Clinical Trial of Etomidate Vs. Propofol for Procedural Sedation During Fracture and Dislocation Reduction in the Emergency Department

Propofol for Procedural Sedation in a Community Emergency Department

Previous experience with simulated pediatric cardiac arrests (that is, mock codes) suggests frequent deviation from American Heart Association (AHA) basic and advanced life support algorithms. During highly infectious outbreaks, acute resuscitation scenarios may also increase the risk of insufficient personal protective equipment (PPE) use by health care workers (HCWs). Simulation was used as an educational tool to measure adherence with PPE use and pediatric resuscitation guidelines during simulated cardiopulmonary arrests of 2009 influenza A patients.A retrospective, observational study was performed of 84 HCWs participating in 11 in situ simulations in June 2009. Assessment included (1) PPE adherence, (2) confidence in PPE use, (3) elapsed time to specific resuscitation maneuvers, and (4) deviation from AHA guidelines.Observed adherence with PPE use was 61% for eye shields, 81% for filtering facepiece respirators or powered air-purifying respirators, and 87% for gown/gloves. Use of a “gatekeeper” to control access and facilitate donning of PPE was associated with 100% adherence with gown and respirator precautions and improved respirator adherence. All simulations showed deviation from pediatric basic life support protocols. The median time to bag-valve-mask ventilation improved from 4.3 to 2.7 minutes with a gatekeeper present. Rapid isolation carts appeared to improve access to necessary PPE. Confidence in PPE use improved from 64% to 85% after the mock code and structured debriefing.Large gaps exist in the use of PPE and self-protective behaviors, as well as adherence to resuscitation guidelines, during simulated resuscitation events. Intervention opportunities include use of rapid isolation measures, use of gatekeepers, reinforcement of first responder roles, and further simulation training with PPE.

Propofol for Procedural Sedation in the Pediatric Patient

Study Objectives: Numerous procedures requiring sedation for pediatric patients, such as orthopedic reduction, lumbar puncture, diagnostic testing, and laceration repair are carried out by emergency physicians. To achieve a more safe and effective means of sedation than current sedatives provide, we initiated the use of propofol, which has a theoretical advantage of rapid onset of action and a short half-life, in our community emergency department.

A retrospective review of a propofol procedural sedation protocol in a community hospital

Study objectives: We evaluate a newly implemented propofol procedural sedation protocol at our institution for efficacy, safety, and adherence to the protocol guidelines and make recommendations to change the protocol if required. Methods: This was a retrospective medical record review of all patients older than 16 years who received propofol for procedural sedation using a preprinted protocol in the emergency department (ED) or critical care unit between January 2002 and November 2002. The protocol dosing for propofol was based on age, weight, and concurrent opioid use: patients aged 16 to 55 years received a 0.5 mg/kg intravenous bolus of propofol and then 10 to 20 mg intravenously every 30 to 60 seconds as needed; patients aged 55 or older or younger patients receiving concurrent opioids received a 0.25 mg/kg intravenous bolus of propofol, followed by 10 to 20 mg intravenously every 1 to 2 minutes as needed. We recorded data to evaluate the efficacy and safety of current protocol guidelines. Results: Forty-seven patients were included in the study, and their demographics, dosing information, and adverse events were recorded on standardized data collection forms. Electrocardioversion was performed on 27 (57%) patients, whereas 20 (43%) patients underwent various emergency procedures. The average total propofol dose received was 90.3 mg (±53.1 mg), and the average number of doses given was 3.6 (±2.1). The average time to sedation from initial propofol dose was 4.2 minutes (±4.0 minutes). Sedation scores were recorded for 25 patients (53%); effective sedation was achieved in 68% of these patients. Adverse events occurred in 10 patients (21%); none of them were critical or resulted in prolonged hospital stay or admission. The propofol bolus dosing guidelines were adhered to in only 43% of patients. Conclusion: The protocol demonstrated suboptimal efficacy but appeared to be safe. According to the results, we recommended increasing propofol bolus doses to allow for faster and more effective sedation. The dose changes were propofol 0.8 mg/kg for patients aged 16 to 55 years and propofol 0.4 mg/kg for patients 55 years or older; dosing adjustment for patients with concurrent opioid use was eliminated.

Propofol for procedural sedation in the pediatric emergency department

This retrospective case series reports our experience using propofol for procedural sedation in the Emergency Department over an 18-month period with 52 pediatric patients. Propofol sedation was performed successfully in all children (mean age, 10.2 years; range 0.7–17.4 years). Indications for sedation included orthopedic manipulation, incision and drainage of abscess, sexual assault examination, laceration repair, and non-invasive imaging studies. The mean dose administered with the intermittent bolus and continuous infusion methods of delivery was 4.25 mg/kg (± 1.86) and 8.3 mg/kg/h, respectively. The mean recovery time was 27.1 min (± 15.84). No patient required assisted ventilation or developed clinically significant hypotension. Respiratory depression requiring airway repositioning or supplemental oxygen was noted in 5.8% (3/52) patients. Propofol is a reasonable alternative to facilitate sedation for a range of procedures performed in a busy Pediatric Emergency Department.

Propofol for procedural sedation in children in the emergency department

Study objective We determine the safety and efficacy of propofol sedation for painful procedures in the emergency department (ED). Methods A consecutive case series of propofol sedations for painful procedures in the ED of a tertiary care pediatric hospital from July 2000 to July 2002 was performed. A sedation protocol was followed. Propofol was administered in a bolus of 1 mg/kg, followed by additional doses of 0.5 mg/kg. Narcotics were administered 1 minute before propofol administration. Adverse events were documented, as were the sedation duration, recovery time from sedation, and total time in the ED. Results Three hundred ninety-three discrete sedation events with propofol were analyzed. Procedures consisted of the following: fracture reductions (94%), reduction of joint dislocations (4%), spica cast placement (2%), and ocular examination after an ocular burn (0.3%). The median propofol dose was 2.7 mg/kg. Ninety-two percent of patients had a transient (≤2 minutes) decrease in systolic blood pressure without clinical signs of poor perfusion. Nineteen (5%) patients had hypoxia, 11 (3%) patients required airway repositioning or jaw-thrust maneuvers, and 3 (0.8%) patients required bag-valve-mask ventilation. No patient required endotracheal intubation. Conclusion Propofol sedation is efficacious and can be used safely in the ED setting under the guidance of a protocol. Transient cardiopulmonary depression occurs, which requires vigilant monitoring by highly skilled practitioners. Propofol is well suited for short, painful procedures in the ED setting.

Propofol for procedural sedation in children

Propofol (Diprivan; Astra Zeneca, Wilmington , DE) is a potent anesthetic/sedative agent characterized by rapid onset of sedation and short recovery time. Because of these pharmacologic qualities. propofol has become popular for use during short diagnostic and therapeutic procedures in outpatient settings for hotly adults and children. For induction of sedation, propofol is slowly administered intravenously as a bolus of 1 to 3 followed by either repeated boluses or a continuous infusion of 50 to 160 μ/kg/min. Because propofol is a pure Sedative the administration of an analgesic agent during painful procedures is recommended. Children sedated with propofol may dot clop arterial oxygen desaturation and/ow a decrease in mean arterial blood pressure. These adverse effects ,try usually transient and Most will resolve when the infusion is discontinued. The current experience of nonanesthesiologist using propofol in the pediatric emergency department is very limited. Although emergency physicians are well qualified in managing airway emergencies, further studies are needed to show the safety profile of propofol in this setting.

Propofol for sedation

In fact, we have used propofol for procedural sedation and as an induction agent for intubation since 1995. Among our emergency physicians it has become the agent of choice (in combination with appropriate analgesia), particularly for orthopedic procedures. Although we have not been tracking its use, we are unaware of any adverse outcomes. Due to its rapid onset, short duration, and ease of titration, we find it easier to employ when one physician performs the procedure while another manages the sedation. We have been performing policydriven conscious sedation since the mid-1980s. Our procedural sedation policy was written in consultation with our Anesthesia Department and has their approval. Although the policy does