CJEM Articles: propofol
Displaying 1-4 of 4 results
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September
2010
12
5
David W. Messenger, Heather E. Murray, Janet van Vlymen, Marco L.A. Sivilotti, Paul E. Dungey
Objective: Important questions remain regarding how best to monitor patients during procedural sedation and analgesia (PSA). Capnometry can detect hypoventilation and apnea, yet it is rarely used in emergency patients. Even the routine practice of performing preoxygenation in low-risk patients is controversial, as supplementary oxygen can delay the detection of respiratory depression by pulse oximetry. The purpose of this study was to determine whether the capnometer or the pulse oximeter would first detect respiratory events in adults breathing room air.
Methods: During a randomized clinical trial comparing fentanyl with low-dose ketamine for PSA with titrated propofol, patients were monitored using pulse oximetry and continuous oral–nasal sampled capnography. Supplemental oxygen was administered only for oxygen desaturation. Sedating physicians identified prespecified respiratory events, including hypoventilation (end-tidal carbon dioxide > 50 mm Hg, rise of 10 mm Hg from baseline or loss of waveform) and oxygen desaturation (pulse oximetry < 92%). These events and their timing were corroborated by memory data retrieved from the monitors.
Results: Of 63 patients enrolled, 57% (36) developed brief oxygen desaturation at some point during the sedation. All responded to oxygen, stimulation or interruption of propofol. Measurements of end-tidal carbon dioxide varied substantially between and within patients before study intervention. Hypoventilation (19 patients, 30%) was only weakly associated with oxygen desaturation (crude odds ratio 1.4 [95% confidence interval 0.47 to 4.3]), and preceded oxygen desaturation in none of the 12 patients in whom both events occurred (median lag 1:50 m:ss [interquartile range 0:01 to 3:24 m:ss]).
Conclusion: During PSA in adults breathing room air, desaturation detectable by pulse oximeter usually occurs before overt changes in capnometry are identified.
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November
2007
9
6
David W. Harrison, Peter J. Zed, Riyad B. Abu-Laban, Winnie W.Y. Chan
Objective: We evaluated the efficacy, safety and patient satisfaction with the use of propofol for procedural sedation and analgesia in the emergency department (ED).
Methods: All patients receiving propofol for procedural sedation and analgesia in the ED between December 1, 2003, and November 30, 2005, were prospectively assessed. Propofol was administered using a standardized protocol, which included an initial dose of 0.25-0.5 mg/kg followed by 10-20 mg/minute until sedated. Efficacy was evaluated using procedural success rate, recovery time and physician satisfaction. Adverse respiratory effects were defined as apnea for more than 30 seconds or an oxygen saturation of less than 90%. Hypotension was defined as systolic blood pressure < 90 mm Hg or > 20% decrease from baseline. Patient and physician satisfaction were determined using 5-point Likert scales.
Results: Our study included 113 patients with a mean age of 50 (standard deviation [SD] 19) years; 62% were male. The most common procedures were orthopedic manipulation (44%), cardioversion (37%), and abscess incision and drainage (13%). The mean total propofol dose required was 1.6 (SD 0.9) mg/kg. Procedural success was achieved in 90% of cases and the mean patient recovery time was 7.6 (SD 3.4) minutes. No patient (0%, 95% confidence interval [CI] 0%-3%) experienced apnea; however, 1 patient (1%, 95% CI 0%-5%) experienced emesis, which resulted in an oxygen saturation < 90%. Nine patients (8%, 95% CI 4%-15%) experienced hypotension and 7 (6%, 95% CI 3%-12%) experienced pain on injection. All patients were very satisfied (92%, 95% CI 85%-96%) or satisfied (8%, 95% CI 4%-15%), and 94% (95% CI 88%-98%) reported no recollection of the procedure. The majority of physicians were very satisfied (85%, 95% CI 77%-91%) or satisfied (6%, 95% CI 3%-12%) with the sedation and the conditions achieved.
Conclusion: When administered as part of a standardized protocol, propofol appears to be a safe and effective agent for performing procedural sedation and analgesia in the ED, and is associated with high patient and physician satisfaction.
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March
2006
8
2
David A. Petrie, David G. Urquhart, George J. Kovacs, John M. Tallon, Kirk D. Magee, Linda Hutchins, Robert McKinley, Sam G. Campbell
Objectives: To examine the safety of emergency department (ED) procedural sedation and analgesia (PSA) and the patterns of use of pharmacologic agents at a Canadian adult teaching hospital.
Methods: Retrospective analysis of the PSA records of 979 patients, treated between Aug. 1, 2004, and July 31, 2005, with descriptive statistical analysis. This represents an inclusive consecutive case series of all PSAs performed during the study period.
Results: Hypotension (systolic blood pressure ≤ 85 mm Hg) was documented during PSA in 13 of 979 patients (1.3%; 95% confidence interval [CI] 0.3%-2.3%), and desaturation (SaO 2 ≤ 90) in 14 of 979 (1.4%; CI 0.1%-2.7%). No cases of aspiration, endotracheal intubation or death were recorded. The most common medication used was fentanyl (94.0% of cases), followed by propofol (61.2%), midazolam (42.5%) and then ketamine (2.7%). The most frequently used 2-medication combinations were propofol and fentanyl (P/F) followed by midazolam and fentanyl (M/F), used with similar frequencies 58.1% (569/979) and 41.0% (401/979) respectively. There was no significant difference in the incidence of hypotension or desaturation between the P/F and M/F treated groups. In these patients, 9.1% (90/979) of patients received more than 2 different drugs.
Conclusions: Adverse events during ED PSA are rare and of doubtful clinical significance. Propofol/fentanyl and midazolam/fentanyl are used safely, and at similar frequencies for ED PSA in this tertiary hospital case series. The use of ketamine for adult PSA is unusual in our facility. -
October
2001
3
4
Kerry Wilbur, Peter J. Zed
Objective: We conducted a qualitative systematic review to evaluate the efficacy and safety of propofol for direct current cardioversion (DCC), rapid sequence intubation (RSI) and procedural sedation in adult emergency department (ED) patients.
Data source: MEDLINE (1966 to September 2000), PubMed (to September 2000), EMBASE (1988 to September 2000), Database of Systematic Reviews (to September 2000), Best Evidence (1991 to September 2000) and Current Contents (1996 to September 2000) databases.
Study selection: English-language, randomized, comparative evaluations of propofol for procedures routinely conducted in adults (>18 years) were included. Direct current cardioversion, RSI and procedural sedation were considered.
Data extraction: Efficacy and safety endpoints were evaluated for all trials. For DCC and procedural sedation trials, efficacy measures included induction and recovery times, as well as the association for successful procedure. For the RSI trials, optimal intubating conditions were evaluated as the primary efficacy endpoint. Safety measures included hemodynamic changes, apnea rates and adverse effects.
Data synthesis: In the setting of DCC, efficacy and safety outcomes were similar for propofol, thiopental, etomidate and methohexital. All of these agents provided markedly shorter induction and recovery times than midazolam. Patients who were pre-medicated with fentanyl exhibited prolonged recovery times and greater decreases in blood pressure. When used for RSI, propofol administration was associated with satisfactory intubating conditions that were comparable to those seen with thiopental and etomidate. Blood pressure reductions were seen in both DCC and RSI studies. Apneic episodes (>30 seconds) occurred in 23% of propofol recipients, 28% of thiopental recipients and 7% of etomidate and midazolam recipients. Apart from the DCC studies described, no procedural sedation studies met our predefined review eligibility criteria.
Conclusion: The body of literature evaluating propofol for DCC and RSI in the ED is limited. There is evidence to support the use of propofol for DCC and RSI, but this evidence comes from stable patients in non-ED settings. Further ED-based randomized comparative trials should be conducted before propofol is adopted for widespread use in the ED.
