Use Of Propofol For Sedation Research Articles

Impact of Pharmacist Monitoring of Serum Triglycerides for Critically Ill Patients Receiving Propofol

Background: Elevated serum triglycerides due to the use of propofol for sedation in the ICU is associated with adverse effects and serum triglyceride monitoring may be improved by pharmacists. Objective: To determine if there was improvement in serum triglyceride monitoring in ICU patients receiving propofol for sedation after implementation of a pharmacist-driven triglyceride monitoring protocol. Methods: This was a single-center pre-post-intervention retrospective cohort study. The protocol was implemented on January 10 2019. Data were collected over 1 year, and patients were divided between those started on propofol before and after protocol implementation. Results: There were 412 patients included in the final analysis with no significant differences between groups. There was a significant increase in the number of patients who had a triglyceride concentration obtained after protocol implementation (31.1% pre-vs 64.0% post-protocol; P < .001). For patients on propofol greater than 24 h, there was a significant increase in baseline triglyceride concentration obtained (7.6% pre-vs 15.1% post-protocol; P = .043). More instances of elevated triglyceride concentrations were identified by pharmacists than other providers (9 vs 5; P < .001). Time between propofol being ordered and first triglyceride concentration ordered was shorter (.86 days pre-protocol vs .71 days post-protocol; P = .064), but not statistically significant. Conclusion: Implementation of a pharmacist-driven protocol in the ICU increased the number of serum triglyceride levels obtained for patients receiving propofol for sedation. Pharmacists can improve triglyceride monitoring in patients receiving propofol and future studies should investigate the impact on outcomes.

A CASE OF PROPOFOL-RELATED INFUSION SYNDROME IN SARS-COV-2

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Propofol-related infusion syndrome (PRIS) is a rare and serious effect of propofol infusion for sedation in critically ill patients. Though there has been an association seen with higher doses of propofol and prolonged infusion times, usually greater than 24 to 48 hours. CASE PRESENTATION: We present a case of an 86-year-old man with history of bradycardia and an implanted permanent pacemaker who was admitted for acute hypoxic respiratory failure caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia. Throughout hospital stay, this patient had progressively increasing oxygen requirements with appropriate escalation in level of care to the ICU. Due to increasing hypoxia despite non-invasive ventilation, the patient was intubated on day 4 of hospitalization, placed on vasopressors and started on sedation, which included continuous propofol infusion. On day 6 of hospitalization, the patient developed worsening hypotension requiring increased levels of sedation and significant lab abnormalities compared to labs collected the day prior. The patient was noted to have elevated potassium to 5.8 mmol/L, creatinine elevation to 2.41 mg/dL from 1.36 mg/dL, and elevated AST of 184 U/L and ALT of 95 U/L from normal levels. Lactate was 4.5, and creatinine kinase was 1317. Six hours later, repeat liver function tests revealed AST of 2078 U/L and ALT of 966 U/L. In the setting of sudden onset rhabdomyolysis, acute kidney injury, and lactic acidosis, there was concern for PRIS and propofol was discontinued. After extended discussion with the family, aggressive measures including dialysis were declined, and patient died. Of interest, the patient's pacemaker likely prevented the patient from developing bradycardia, classically seen in PRIS. DISCUSSION: Challenges with sedation of intubated patients with SARS-CoV-2 have been clinically observed and deeper sedation levels have been required to promote ventilator synchrony. Propofol continues to be a first-line sedative in critically ill patients, including SARS-CoV-2 patients. These patients require sedation higher infusion rates compared and are therefore at higher risk. Our patient was maintained on 20mcg/kg/min for 27 hours, then subsequently on 45 mcg/kg/min for 34 hours thereafter. Therefore, our patient was at increased risk of PRIS given propofol infusion at high doses was maintained for longer than 24 hours. Moreover, the concurrent use of vasopressors placed him at increased risk. CONCLUSIONS: Although propofol is recommended as a first-line anesthetic agent in critically ill patients with SARS-CoV-2 requiring sedation, the multiorgan failure resulting from PRIS is potentially fatal. Early recognition is crucial for management, which includes discontinuing propofol infusion and hemodialysis if indicated. REFERENCE #1: Hanidziar D, Bittner EA. Sedation of Mechanically Ventilated COVID-19 Patients: Challenges and Special Considerations. Anesth Analg. 2020;131(1):e40-e41. doi:10.1213/ANE.0000000000004887 REFERENCE #2: Payen JF, Chanques G, Futier E, Velly L, Jaber S, Constantin JM. Sedation for critically ill patients with COVID-19: Which specificities? One size does not fit all. Anaesth Crit Care Pain Med. 2020;39(3):341-343. doi:10.1016/j.accpm.2020.04.010 REFERENCE #3: Yamamoto K. Risk of propofol use for sedation in COVID-19 patient. Anaesthesiology Intensive Therapy. 2020;52(4):354-355. doi:10.5114/ait.2020.100477. DISCLOSURES: No relevant relationships by Sravani Gajjala, source=Web Response No relevant relationships by Oki Ishikawa, source=Web Response No relevant relationships by Stacey Jou, source=Web Response No relevant relationships by Zein Kattih, source=Web Response No relevant relationships by Vinayak Shenoy, source=Web Response

The effect of adenosine triphosphate on propofol-induced myopathy in rats: a biochemical and histopathological evaluation.

Propofol infusion syndrome characterized by rhabdomyolysis, metabolic acidosis, kidney, and heart failure has been reported in long-term propofol use for sedation. It has been reported that intracellular adenosine triphosphate (ATP) is reduced in rhabdomyolysis. The study aims to investigate the protective effect of ATP against possible skeletal muscle damage of propofol in albino Wistar male rats biochemically and histopathologically. PA-50 (n = 6) and PA-100 (n = 6) groups of animals was injected intraperitoneally to 4 mg/kg ATP. An equal volume (0.5 ml) of distilled water was administered intraperitoneally to the P-50, P-100, and HG groups. One hour after the administration of ATP and distilled water, 50 mg/kg propofol was injected intraperitoneally to the P-50 and PA-50 groups. This procedure was repeated once a day for 30 days. The dose of 100 mg/kg propofol was injected intraperitoneally to the P-100 and PA-100 groups. This procedure was performed three times with an interval of 1 days. Our experimental results showed that propofol increased serum CK, CK-MB, creatinine, BUN, TP I, ALT, AST levels, and muscle tissue MDA levels at 100 mg/kg compared to 50 mg/kg and decreased tGSH levels. At a dose of 100 mg/kg, propofol caused more severe histopathological damage compared to 50 mg/kg. It was found that ATP prevented propofol-induced muscle damage and organ dysfunction at a dose of 50 mg/kg at a higher level compared to 100 mg/kg. ATP may be useful in the treatment of propofol-induced rhabdomyolysis and multiple organ damage.

Propofol-Associated Priapism in a Prepubescent Pediatric Patient.

Introduction. Propofol is a commonly used sedative medication for procedural sedation with a limited side effect profile. Although well tolerated with minimal adverse reactions, uncommon side effects have been reported. Methods. Case report of priapism in a 9-year-old male following the use of propofol for sedation in the pediatric intensive care unit (PICU) setting. The patient was admitted to the PICU for postoperative management following laryngotracheal reconstruction. On postoperative day 2, our patient was initiated on continuous infusion of propofol and he developed priapism. Propofol was then immediately discontinued, and the priapism quickly resolved without any medical or surgical interventions. Results. Priapism is a low-flow state and is considered a urological emergency requiring prompt recognition, withdrawal of suspected offending agents, and possible need for urologic consultation to alleviate complications. Although rare, priapism with propofol has been reported but never in a prepubescent male. The mechanism of propofol-associated priapism is not well understood, but it is thought that it may result from an autonomic system imbalance, leading to an increase in parasympathetic activity. In addition, propofol has been shown to affect nitric oxide–mediated smooth muscle relaxation. In our patient, we suspected propofol to be contributing factor to his priapism based on the temporal relationship between the initiation of the medication and symptoms and resolution of symptoms after propofol discontinuation. Discussion. Given the expansive use of propofol in pediatrics for sedation and anesthesia, pediatric clinicians should be cognizant of this rare adverse effect in pediatric patients with potentially disastrous complications.

203 Vasopressor Use During Acute Fluid Resuscitation in Burn Patients

It is not known why some burn patients require vasopressor (VP) drugs during the acute fluid resuscitation phase. The purpose of this study was to evaluate factors that predict VP administration during acute burn resuscitation. Retrospective analysis of patients with burns ≥ 20% TBSA admitted within 24 hours post burn (PB) to an adult regional ABA-verified burn center between 11/15/15 and 7/1/17. Patients that received a VP in the 1st 48 hours (PRESS) were compared to those who did not (NOPRESS). Values are shown as the mean ± SD or median (1st, 3rd quartiles) as appropriate. There were 49 patients that met inclusion criteria. Following exclusion for VP administration prior to arrival at the BC (n=3) or provision of comfort measures ≤ 24 hours PB (n=9), a study population of 37 subjects remained. This population’s characteristics were age 47 ± 16 yrs, 35% female, with %TBSA burn 32 (24.5,49.2) and % full thickness burn 20.5 (3.3,39.8), and 32% with inhalation injury (INH). In the PRESS group, VPs were initiated at 24.3 ± 13 h PB, and were continued for 13.9 ± 10.5 h during the 1st 48 h PB period. The total amount of resuscitation fluid administered up to the initiation of VPs was 4.1 ± 2.2 mL/kg/%TBSA burn, and at the start of VPs, 119.6 ± 55.1 % of predicted resuscitation fluid had been infused. The 1st VP was norepinephrine in all cases. Vasopressin was added in two cases and epinephrine was added in 4 cases. PRESS and NOPRESS are compared in the table. There were no differences between the groups in % of predicted resuscitation fluid administered at 6,12, and 24 h PB, urine output, use of propofol for sedation, or the dose of opioids and benzodiazepines at 24 and 48 hours PB. High dose vitamin C had been used in 47% of PRESS resuscitations and in 23% of NOPRESS resuscitations (p=0.127). Only age was a significant predictor of need for VPs [OR 1.17 (95%CI: 1.01–1.36)]. Advanced age appears to be the main predictor of the need to initiate VPs during acute fluid resuscitation after burns. However, this study is limited by a small sample size and other factors may be contributory. VPs may be required in older patients despite acceptable fluid provision, during acute burn resuscitation.

Effects of propofol sedation on pacing thresholds : Results from an observational cohort study.

Propofol is one of the most commonly used intravenous anaesthetic drugs for surgical procedures. The use of propofol for sedation is also common practice during endoscopic procedures, electrophysiology studies, and ablation procedures, as well as pacemaker and defibrillator implantation. It was found that propofol alters the electrophysiologic properties of the heart and its conduction system. The effects of propofol on pacing thresholds are unknown and could have implications for pacemaker (PM) and defibrillator (ICD) implantation procedures, as well as sedation and anaesthesia in PM and ICD patients in general. We sought to investigate the effects of propofol sedation on atrial and right ventricular pacing thresholds in PM and ICD patients. A total of 50patients with PM, ICD, or cardiac resynchronization therapy (CRT) undergoing propofol sedation for electrophysiology (EP) investigation, transesophageal echocardiography (TEE), electrocardioversion (ECV), or bronchoscopy were included prospectively. Pacing thresholds, impedance, and sensing were assessed by device interrogation immediately prior to sedation and after the desired sedation depth was achieved by the administration of propofol. Mean atrial (0.68 V vs 0.77 V, p= 0.136) and mean right ventricular thresholds (0.90 V vs 0.93 V, p= 0.274) remained unchanged. Impedances and sensing remained unaffected in all patients. Propofol sedation did not affect pacing thresholds of atrial and right ventricular leads in this cohort of PM and ICD patients.

Italian Society of Digestive Endoscopy (SIED) position paper on the non-anaesthesiologist administration of propofol for gastrointestinal endoscopy

Propofol sedation by non-anesthesiologists in GI endoscopy, despite generally considered a safe procedure, is still a matter of debate. Benefits of propofol sedation include rapid onset of action, greater patient comfort and fast recovery with prompt discharge from the endoscopy unit.The use of propofol for sedation in GI endoscopy, preceded by dedicated training courses, has been approved by several anaesthesiologist and gastroenterologist societies but an Italian position paper taking into account the Italian law is lacking.In the present document, the Italian Society of Digestive Endoscopy (SIED) Sedation Group, on behalf of the SIED, presents a series of updated position statements concerning propofol sedation in GI endoscopy. The paper summarizes the advantages of propofol, how it should be administered and how patients should be monitored. Moreover, details concerning proper training of non-anaesthesiologist personnel involved in its use are provided. Protocols concerning propofol use s must be shared with the hospital's anaesthesiology staff and approved by the hospital’s Executive Director.

Bronchoscopist-directed Continuous Propofol Infusion for Targeting Moderate Sedation During Endobronchial Ultrasound Bronchoscopy

Propofol use for sedation during routine flexible bronchoscopy is expanding. However, there are concerns over propofol's reliability in targeting moderate sedation during more complex and lengthy procedures, such as endobronchial ultrasound (EBUS) bronchoscopy. Its delivery by continuous infusion, which provides a steady sedation effect, may be a practical model for achieving reliable outcomes in this setting. We tested a continuous propofol infusion protocol targeting moderate sedation for EBUS bronchoscopy. A fixed loading rate of 125 mcg/kg/min and initial maintenance rate of 75 mcg/kg/min were used. Sedation assessments were performed every 2.5 minutes. The infusion was adjusted by a nurse under the direction of the bronchoscopist to maintain moderate sedation, normal vital signs, and patient comfort. Prospectively collected data from the first 31 patients using the protocol were analyzed. A mix of EBUS types was performed in a fellowship training environment. Median procedure duration was 51 minutes (interquartile range, 41 to 75 min). Ninety-four percent of total bronchoscopy time was spent in moderate sedation, whereas only 1.9% was occupied by agitation-related delays. Average propofol dose per case was 0.07 mg/kg/min (±0.020), and infusion adjustments were required once every 8 minutes. Sampling goals were met in all patients, and diagnostic and nodal staging accuracies were 90% and 91%, respectively. All tumor specimens sent for genetics were sufficient for analysis. There were no major procedure-related complications. Bronchoscopist-directed continuous propofol infusion is effective and practical for reliably and safely targeting moderate sedation during EBUS bronchoscopy, without sacrificing the breadth and accuracy of the procedure.

Effectiveness of remifentanil & propofol infusion for procedural sedation in patients undergoing gastrointestinal endoscopic procedures: a systematic review protocol

Effectiveness of remifentanil & propofol infusion for procedural sedation in patients undergoing gastrointestinal endoscopic procedures: a systematic review protocol

Cost-Based Comparison of Anesthetist-Administered Propofol Versus Endoscopist-Directed Propofol as Sedation During Screening Colonoscopies in an Academic University Center

Introduction: Propofol use for sedation during colonoscopy is gaining wider acceptance, due, in part, to a better-reported safety profile, shorter recovery times, and better intra-procedure tolerability. However, requirements for administration of the agent differ markedly. In most academic settings, there is a requirement for the presence of an anesthetist during the procedure, which is not usually the case in non-academic settings, where endoscopist-directed administration prevails. Our aim was to perform a cost-based analysis of the presence of an anesthetist during colonoscopies performed under propofol sedation as compared to endoscopist-directed propofol administration. Methods: We retrospectively evaluated 20 colonoscopies performed for colorectal cancer (CRC) screening by a single certified endoscopist using propofol in the absence of an anesthetist or certified registered nurse anesthetist (CRNA), and determined the average duration per procedure. Timebased billing charges for the presence of an anesthetist during a colonoscopy were obtained from the billing department (5 units+duration of procedure; each unit=15 minutes or $80). The mean hourly wage of a CRNA was obtained from the Bureau of Labor Statistics, U.S. Department of Labor ($74.22, May 2012). Results: The average duration of a colonoscopy with indications as above, performed under endoscopistdirected Propofol, was 19.5 minutes. The average per procedure charge for the presence of an Anesthetist was calculated as $504. Conclusion: In a large university setting, the per procedure cost of anesthetist-administered propofol during routine colonoscopies for CRC screening is markedly higher than that with endoscopist-directed propofol administration, with a per-procedure cost difference of at least $504. The anesthetist’s time for intubation, induction of anesthesia, and recovery was not taken into account and could add considerably to this cost. The cost of training a gastroenterologist was also not considered; however, this is likely to have a minimal impact on the difference. In a private practice setting, routine use of a CRNA is common; however, the per procedure additional cost would remain low (per our observations, an addition of $24.12 per procedure). Growing evidence suggests that with appropriate patient selection and training, gastroenterologists can safely and effectively administer propofol during colonoscopies. There is also some evidence that anesthetists target deeper sedation with larger doses of propofol, potentially placing the patient at a higher risk for complications; hence, with appropriate training, endoscopist-guided propofol administration during colonoscopies can be a cost-effective and safe alternative to the presence of an anesthetist in any healthcare setting.

Propofol-Associated Priapism in a Pediatric Patient

Objective: To report a case of priapism in an adolescent male following the use of propofol for sedation. Case Report: A 13-year-old male with developmental delay was admitted to intensive care secondary to pneumonia and persistent paroxysmal choreoathetosis. In attempt to stop the choreoathetosis and progressive rhabdomyolysis, he was sedated with 50 mg of intravenous propofol, which successfully resolved the choreoathetosis. Within minutes after the injection, he developed priapism, and within 1 hour it resolved without intervention. Discussion: Priapism was considered to be caused by propofol based on temporal relationship, lack of other medications administered, and complete resolution of symptoms after withdrawal. An objective causality assessment based on the Naranjo adverse drug reaction probability scale suggests propofol is a probable cause of the priapism in our patient. The mechanism of propofol-induced priapism is unknown but likely occurs due to both local and systemic effects. Conclusion: Pediatric clinicians should be aware of this rare side effect, as it requires prompt recognition and potential urologic intervention to alleviate complications.

Comparison between Intermittent Propofol Bolus Techniques and Target-Controlled Infusion in Patients Underwent Gastrointestinal Endoscopy

Background : Nowadays, the use of propofol for sedation during gastrointestinal endoscopic procedure has become more popular, either by intermittent-bolus (IB) technique or target-controlled infusion (TCI). The aim of this study was to compare the outcomes of both techniques including the total consumption of propofol, consumption per minute, total cost, side effects and its recovery time. Method : This study was a single-blinded randomized clinical trial conducted at Digestive Endoscopy Center, Cipto Mangunkusumo Hospital, Jakarta between October and November 2013. There were fifty patients with pre-operative American Society of Anesthesiologist (ASA) Physical Status Classification I-III, aged 18-65 years, body mass index 18-30 kg/m2 who were randomized to obtain sedation with IB propofol or TCI after having a premedication with 1 μg/kgBW fentanyl. The outcomes including the duration of sedation, total dose, propofol consumption per minute, the total cost, the incidence of hypotension, the incidence of desaturation, and recovery time were then evaluated using SPSS version 21.0. Results : Duration of procedure between two groups was not significantly different (p = 0.718). Total dose of propofol, its consumption per minute and total cost were higher in TCI group (p = 0.010; p = 0.004; p = 0.001). The incidence of hypotension, desaturation and recovery time were not significantly different (p = 0.248; p = 0.609; p = 0.33) in both groups. Conclusion : IB technique is more efficient in terms of total propofol dose, consumption per minute and total cost compared to the TCI technique. The incidences of hypotension, desaturation and recovery time profiles were comparable between the two groups. Keywords: gastrointestinal endoscopy, intermittent bolus, propofol, sedation, TCI

Postanesthesia Persistent Amnesia in a Patient With a Prior History of Dissociative Fugue State: The Case for the Two-Hit Hypothesis

The psychiatry service was called to evaluate a patient in the outpatient procedure unit who could not remember who she was or why she was there. “Ms. R” was a 36-yearold Hispanic woman with a history of morbid obesity who underwent an upper endoscopy for evaluation of nausea and inability to tolerate oral intake 1 month after a Roux-en-Y gastric bypass for her obesity. The endoscopy demonstrated moderate stenosis at the gastrojejunal anastomosis, which did not account for the severity of her nausea. The stenosis was dilated without incident. For the procedure, Ms. R received a total of 420 mg i.v. of propofol, 100 mg i.v. of lidocaine, and 0.2 mg i.v. of glycopyrrolate. She also received a total of 200 μg i.v. of phenylephrine for a transient decrease in blood pressure to 81/45. In the recovery room, when Ms. R awoke from her conscious sedation, she had no recollection of why she was in the hospital, was disoriented to place, and, most significantly, was unable to recall her identity. She was agitated, prompting the psychiatric consultation. Ms. R was visibly frightened when any person tried to approach her, including her boyfriend of 5 years. She repeatedly asked why she was there but was unable to retain the information received. She was given 2 mg of midazolam for agitation, after which a minor improvement in behavior was observed. A repeat dose of midazolam was administered, without further improvement. Forty-five minutes after the procedure, Ms. R was still unable to recall her date of birth. Her vital signs and general physical and neurological examination were within normal limits. Her mental status examination was significant for agitation, disorientation to person and place, and extensive memory loss, which continued for the rest of the day. She repeatedly expressed the delusion that the baby she had just delivered was taken from her. She had no evidence of hallucinations. A preprocedure pregnancy test was negative. Ms. R was on a liquid diet and taking a multivitamin once daily, 1,000 μg of vitamin B12 three times a week sublingually, and calcium citrate daily. Ms. R’s past medical history included a history of gallstones as well as the Roux-en-Y gastric bypass surgery 1 month earlier, at which time her body mass index (BMI) was 47. Ms. R had received 200 mg of propofol as part of the anesthesia during the 3-hour bariatric surgery without incident. Ursodiol was begun 3 weeks before the endoscopy for nausea that developed while she was consuming a postoperative liquid diet. When her diet was advanced to soft foods, she began vomiting. She returned to a liquid diet, and the endoscopy was scheduled. Ms. R’s past psychiatric history was significant for a dissociative fugue, which occurred at the same time as her divorce 7 years earlier and for which she was psychiatrically hospitalized. She continued in individual and group treatment for 2 years after that hospitalization. She had no history of traumatic events. Because of Ms. R’s persistent amnesia and agitation, she was admitted to amedical unit for further evaluation. Results of all testing, routine laboratory tests, urine drug screen, head CT, head MRI, and EEG were normal except for ketones in the urine. Ms. R’s BMI had decreased to 40.5. She was started on a clear liquid diet and had no further nausea. The neurology consultant agreed with the psychiatrist’s diagnosis of dissociative amnesia. During her hospitalization, Ms. R slowly regained some of her memory. She vaguely remembered that she had an adult son living in another state. Ms. R could not remember how to use her cell phone. She was afraid to take a shower without supervision as she was not sure she would know what to do. She also could not recall important historical events, such as the September 2001 attacks on the World Trade Center. There was no evidence of anterograde amnesia after the first hospital day. After showing some improvement over her 6-day hospitalization, she was discharged home with her boyfriend. Two weeks after hospital discharge, Ms. R continued to recover some of her memories and to increase her activities. It was unclear, however, whether her retrograde amnesia was improving or whether she was only retaining newly learned information. She began to cook on her own and reported increased comfort around her boyfriend and her family. Ms. R was afraid to return to work because she was concerned that she would not remember how to do her job. Within 2 months of the episode, Ms. R was retrained by her employer and successfully resumed her work as a secretary. Six months after the procedure, Ms. R’s retrograde amnesia had significantly improved and she continued to form new memories without difficulty.

Nutrition support during extracorporeal membrane oxygenation (ECMO) in adults

Dear Editor We read with interest the article by Ferrie et al. [1] on nutritional support in adult patients receiving extracorporeal membrane oxygenation (ECMO). The authors retrospectively audited 86 patients who received ECMO [venovenous (VV) or venoarterial (VA) mode] and fed using protocols that emphasize early enteral nutrition (EN). It is believed that the hemodynamic alterations which occur in these patients can lead to serious complications, such as mesenteric ischemia. The main finding of this elegant study is that early EN can be well tolerated in such patients (average 79.7 % of target nutrition). However, some obstacles to adequate nutrition were identified, such as the use of propofol for sedation, and 18 patients required parenteral support due to EN intolerance. Intolerance did not differ between ECMO modes. We would like to discuss our recent findings on this subject as a complement to this study by Ferrie et al. [1]. We have recently reported a prospective case series of early EN in seven patients receiving VA ECMO for severe hemodynamic failure unresponsive to conventional therapies [2], as well as a prospective study involving 37 cardiac surgery patients with hemodynamic failure [3]. Although some differences are present in these two studies regarding the applied nutrition protocol and definition of nutritional goal, we came to the same main conclusion: early EN is possible and not associated with serious complications. However, we did note significant energy deficits, especially in patients with a long stay in the ICU ([14 days). Complications such as abdominal distention, diarrhea, and constipation were frequent ([25 % of included patients). These complications barely received any mention in the paper published by Ferrie et al. [1]. We would therefore like to ask the authors about their experience with energy balances using EN alone, as well as a more detailed description of EN-related complications. Despite current recommendations regarding nutritional support in patients with hemodynamic failure [4], we agree with the authors that EN is possible in ECMO patients, always under proper medical supervision. Although controversial, we also consider that EN is also feasible in cardiac surgery patients with hemodynamic failure [5]. More studies are clearly warranted to confirm these findings.

Pre-PRIS? Prospective monitoring for early markers of propofol infusion syndrome

The use of propofol for sedation in intensive care has been associated with the propofol infusion syndrome (PRIS) characterised by cardiac dysfunction, metabolic acidosis, renal failure, rhabdomyolysis and hyperlipidaemia. We prospectively monitor biochemical markers that we believe demonstrate early signs of this dangerous, often fatal syndrome. When this Pre-PRIS state is identified, propofol is withdrawn whilst the syndrome is still reversible.

Are we not there yet? Who can keep the Pandora box safe?

Editor, We agree with the comments made by Delaunay et al.1 and Perel.2 In order to keep the Pandora box safe, we should focus on the following two issues: administration of propofol by nonanaesthesiologists including laypersons and the use (and abuse) during endoscopy. In South Korea, many generic propofol formulations are widely used, not only by anaesthetists but also by gastroenterologists, plastic surgeons, dermatologists and general physicians. The use of propofol for sedation is supposed to be restricted to anaesthetists, but unfortunately, in the real world this is not always the case. In South Korea, tabloid newspapers have reported that some people prefer to visit a hospital multiple times in a month to undergo endoscopies using propofol, not for establishing a diagnosis but for the propofol itself. In our hospital, there were two deaths out of 24 000 endoscopies in 2011. Because there is no antidote for propofol, such as flumazenil for midazolam, it is often considered to be a dangerous drug by nonanaesthesiologists. However, due to controllability and a short recovery time, it is very attractive to use propofol in developing countries with small areas for recovery after endoscopic procedures. In South Korea, the majority of sedation procedures for endoscopy are routinely performed by nonanaesthesiologists. In the area of Seoul, more than 10 doctors were arrested for inappropriate administration of propofol in 2010. None was an anaesthetist. Propofol has been sold and administered by nonmedical staff without any just cause. It has been used as a sleeping drug and the people selling the drug have pocketed huge sums of money. More recently, by virtue of Korean popular music (K-POP), a lot of adolescents are involved in the entertainment field and are taking propofol as a recreational drug. Among young people, propofol is referred to as the white, or milky-white, solution. Propofol was supplied to the hospitals at approximately US$ 4.5 per ampoule of 120 mg in 2011. However, nonmedical staff who injected their ‘clients’ with propofol without undergoing any medical procedure or a recovery room, received up to US$ 400 per ‘procedure’. As stated in many articles, the reported cases of propofol abuse in South Korea may be only the tip of the iceberg.3,4 In South Korea, propofol has been classified as a strictly controlled substance, like opioids, since February 2011. We may have come one step closer to keeping the Pandora box safe, but we, as anaesthetists who use propofol exclusively for endoscopic procedures, have many more steps to take to implement strict product control to prevent the abuse of propofol. Anaesthetists are entirely capable of dealing with the complications of propofol, not only airway and respiratory management but also anaphylaxis,5,6 propofol-related infusion syndrome7,8 as well as anaphylaxis related to single or repeated doses.6 A recent report of propofol-related infusion syndrome is especially alarming.9 It has been advocated that infusions more than 4 mg kg−1 hr−1 for more than 48 h should be avoided.8 However, propofol-related infusion syndrome has also been shown to occur after short-term, high-dose infusions and, the occurrence of this complication cannot be excluded after repeated or single bolus injections. Anaesthetists must keep in mind that ‘hedgehopping’ (i.e. very low altitude flight) is the most dangerous flight, just as is short-term simple sedation. We hope that board members of the European Society of Anaesthesiology, the French Society of Anaesthesiology, the World Society of Anaesthesiology and the Food and Drug Administration keep this in mind. The authors have more than 20 years of experience in the field of anaesthesia, and they are still very cautious when performing monitored anaesthesia care (i.e. so-called sedation), and they would like to advise nonanaesthetists who have acquired some training, skills and attention within a limited time period, to do the same. Let us keep the Pandora box safe. Acknowledgements Assistance with the letter: none declared. Financial support and sponsorship: none declared. Conflicts of interest: none declared.

789 Anesthesiologist Services for Colonoscopy: Practice Patterns in the Medicare Population

Anesthesiologist participation in endoscopy allows the use of propofol for sedation but increases total procedural costs. However, the prevalence of anesthesia for endoscopy and predictors of its use has not been recently studied at a population level.

Prolonged Propofol Use in a Critically III Pregnant Patient

To describe the prolonged use of propofol for sedation of a critically ill pregnant patient in her second trimester. A 20-year-old pregnant woman at 14 weeks' gestation with non-Hodgkin's lymphoma required intubation and mechanical ventilation secondary to tumor-related airway obstruction. Immediately after intubation, propofol was initiated for sedation and maintained for 51 days with only one 5-day interruption in therapy. Over the course of the patient's stay in the intensive care unit, systemic chemotherapy was administered, resulting in a reduction in tumor burden and allowing for successful extubation. Ultimately, the fetus was deemed nonviable and the pregnancy was terminated. Propofol is an intravenous anesthetic agent commonly used for the sedation of mechanically ventilated patients and is the only sedative agent that carries a pregnancy category B rating. Fetal outcomes following long-term use of propofol during the first trimester have not been formally evaluated and few reports of propofol use outside of early pregnancy termination, outpatient procedures, or parturition exist in the medical literature. Our patient required early termination of pregnancy; however, we were unable to determine whether fetal loss was a result of propofol use, chemotherapy administration, the use of other pharmacologic agents, or perhaps a combined effect. Despite propofol's pregnancy category B rating, data are lacking in humans regarding its safe use during pregnancy and long-term developmental outcomes in children after exposure to propofol in utero. The safety of propofol as a sedative agent for critically ill pregnant patients remains unknown.

PWE-007 A single-centre 8-month experience of propofol sedation for endoscopic procedures

Introduction Propofol is being increasingly used for sedation in endoscopic procedures in the US and across Europe, but experience within UK centres remains limited. Over the last few years there has been an anaesthetist covered dedicated propofol sedation endoscopy list at the Leicester General Hospital. The aim was to evaluate the propofol sedation service with respect to current practice and complication rates, with a view to expanding the service and developing appropriate guidelines for more effective use. Methods Review of all endoscopic procedures using propofol for sedation over 8-months at the Leicester General Hospital. Data were collected for all relevant procedures from August 2008 to March 2009. Indication for propofol use was examined, type of procedure, dose of propofol, and significant complications evaluated. Result 48 procedures were done using propofol sedation during Aug 2008–March 2009: 54% OGD; 33% Colonoscopy; 8% PEG; 4% FOS. The patients9 age ranged from 21–78 years (mean 52), with 52% female and 48% male. Of these procedures 45% had no clear indication for the use of propofol, 35% had previously failed the procedure under “standard sedation”, 13% required therapeutic procedures, 8% had other relevant indications for propofol sedation as opposed to standard endoscopic sedation. Dose was documented in 31% of cases, with dose ranging from 120–600 mg propofol (mean 324 mg). 2/48 (4%) had respiratory compromise requiring airway support with bag and mask ventilation for a few minutes. There were 15 pending requests at the time of evaluation: 60% COL; 13% OGD+COL; 13% banding/dilatation; 7% OGD; 7% PEG. Patients9 age range was 25–65 years (mean 49), 67% female and 33% male. In 60% requests there was no reason identified for rationale behind use of propofol, 27% had previously failed procedure under standard sedation, 7% were therapeutic, and 7% were for surveillance purposes. Conclusion There is increasing demand for the use of propofol for sedation in endoscopic procedures within UHL NHS Trust. In our centre there has been effective use of anaesthetist led propofol endoscopy lists with minimal complications and a good level of patient satisfaction. With increasing patient popularity and a greater drive for surveillance and screening procedures in patients, perhaps a formal anaesthetist supported propofol endoscopy service should be established in all endoscopy units. Until more information is available on the safety of use of propofol for diagnostic and therapeutic endoscopy, clear guidelines need to be in place in centres developing a propofol endoscopy service to ensure safe and appropriate use.

Successful Treatment of Propofol-induced Priapism With Distal Glans to Corporal Cavernosal Shunt

We report a case of postoperative pediatric priapism in a boy without a hematologic disorder after a propofol-based general anesthetic. Our case underscores the importance of the early diagnosis and treatment to lessen the risk of complications. Given the wide use of propofol for sedation and anesthesia, clinicians should be cognizant of this rare, but serious, adverse effect that requires emergent attention.