It's cheap - that's the only thing it's got going for it. If you're using enough of it by itself to cause sedation, you're using too much. And why would you want a long-lasting high? Get them in, do the procedure, get them out.
I use straight propofol, period. It's far more efficient than demerol/versed could ever be. The patients love it (especially if they've had fentanyl/demerol/versed cocktails in the past), and GI docs demand it - none of them do their own IV sedation any more. Why should they? My patients are awakening before they leave the procedure room, are chatting by the time we get the first set of vital signs in the PACU, and are dressed and ready to go waiting for the magic 30 minute hospital PACU requirement to go by so they can head out the door. The propofol is long gone and they're N&V free - not so with a bunch of demerol and/or versed. Demerol has to be one of the most emetogenic drugs ever created. Why anyone uses it ever is beyond me.
Playing devils advocate.
The real issue is cost/benefit to the health care system.
Anesthesia charges with commercial insurance can range anywhere from as low as $30/40 a unit to well over $100/unit. The average units billed is between 7-9 units a case. Medicare is around $20/unit
70-80% of patients will be fine with conscious sedation. We know the ones who truly benefit from propofol only anesthesia (aka the sleep apnea population). Maybe the few who have extreme nausea with narcotics.
But benefit/cost to the system. Think about it. We can all try to rationize patients recover faster. GI docs can get through cases faster. But at the end of the day it's an unnecessary expense for a vast majority of patient especially those with high deductibles having diagnostic GI tests (not screenings)
It's an easy thing to tell people to have propofol and they recover faster. Tell that to someone who has a $5000 family deductible than an additional 30% co pay up to a $10000 max in network per year cost.
Costs add up very quickly.
It's all dandy when it's a "screening" colonoscopy and doesn't count against the deductible and "the other guys/insurance company is paying the anesthesia fee. It's another thing when you are paying out of pocket yourself.
The fact is most people will sleep off versed/fentanyl and be fine the next day.
If propofol were super safe and people are fine to go to back to work right away. What are your pacu nurses telling the patient? Are they telling them they can drive home themselves? Are they telling them they can go back to work right away lifting heavy construction material? Hell no! Liability reasons folks. Centers that used propofol only still tell patients not to drive and take it easy rest of the day.
If your center doesn't change the pacu discharge instructions for those having propofol only vs versed/fentanyl. Than what's the real benefit here?
The end game is vast majority of patients having versed/fentanyl will be fine the next day. They are instructed they can drive to work the next day. Which is the same as you tell patients having propofol.
Please let me know of any centers that use propofol that allow patients to drive themselves home and go back to work lifting heavy equipment. I'd love to know about them. (Obviously there are patients that will do that but they do it against medical advice) so we can wash our hands off if there are any problems.
