Propofol Use by Non-Anesthesia Providers

[jwk]

Here's yet another political football worth noting and acting upon.

This is a huge issue for many different reasons, but obviously the most important is patient safety. Those of us who do a lot of MAC cases, and in particular GI cases, know that the reason so many surgeons and gastroenterologists like propofol for MAC cases is that anesthesia providers, more often than not, use propofol for deep sedation, not simply conscious sedation. Personally, I think conscious sedation with propofol is essentially worthless - the same effect is easily achieved with much cheaper (not to mention reversible) medications such as fentanyl and midazolam. The minute that GI docs don't get their desired effect, they're going to be pushing more, and then the patient is in real trouble.

I was around when Versed was first introduced as an alternative to Valium - "oh don't worry, it's just like Valium but doesn't last as long". I can't tell you how many respiratory arrests we had to resuscitate in the endoscopy suite when the GI docs were pushing 10-15mg of Versed.

Propofol use by non-anesthesia trained providers is a bad idea. The GI docs are requesting that the FDA compel manufacturers of propofol to remove the package warnings that propofol should only be administered by anesthesia personnel. Your comments to the FDA against this change are important.



Link to the ASA articles below to see how you can help.

http://www.asahq.org/news/ASAresponse.htm



There is also a group called ASAP - Anesthesiologists for the Safe Administration of Propofol - that is pursuing the same arguments.

http://www.safepropofol.org/

---

Members don't see this ad.

 

[eagle26]

Here's yet another political football worth noting and acting upon.

This is a huge issue for many different reasons, but obviously the most important is patient safety. Those of us who do a lot of MAC cases, and in particular GI cases, know that the reason so many surgeons and gastroenterologists like propofol for MAC cases is that anesthesia providers, more often than not, use propofol for deep sedation, not simply conscious sedation. Personally, I think conscious sedation with propofol is essentially worthless - the same effect is easily achieved with much cheaper (not to mention reversible) medications such as fentanyl and midazolam. The minute that GI docs don't get their desired effect, they're going to be pushing more, and then the patient is in real trouble.

I was around when Versed was first introduced as an alternative to Valium - "oh don't worry, it's just like Valium but doesn't last as long". I can't tell you how many respiratory arrests we had to resuscitate in the endoscopy suite when the GI docs were pushing 10-15mg of Versed.

Propofol use by non-anesthesia trained providers is a bad idea. The GI docs are requesting that the FDA compel manufacturers of propofol to remove the package warnings that propofol should only be administered by anesthesia personnel. Your comments to the FDA against this change are important.



Link to the ASA articles below to see how you can help.

http://www.asahq.org/news/ASAresponse.htm



There is also a group called ASAP - Anesthesiologists for the Safe Administration of Propofol - that is pursuing the same arguments.

http://www.safepropofol.org/

How do you feel about the use of propofol by cardiac surgeons post-CABG and valve replacement procedures to maintain a level of deep sedation? They're not anesthesia trained but they routinely have patients on propofol drips at my institution. I have yet to see adverse outcomes, at least from the proper use of propofol in this setting.

However, I do agree that the use of propofol for endoscopy procedures is quite over the top, so to speak. I haven't seen it done here, we mainly use the versed-fentanyl combo. I'm actually surprised that any endoscopist would consider using propofol for these procedures.

 

[The White Coat Investor]

I disagree that an anesthesia residency in and of itself automatically makes it safe for one to be able to use a specific medication. As long as one is familiar with the dosing, effects, adverse reactions, and contraindications of the medicine, AND has the ability to mitigate its effects...i.e. manage an airway and hypotension, AND has the patient properly monitored (Cardiac monitor, continuous BP, Pulse ox, ETCO2) I think propofol can be very appropriately used by non-anesthesiologist providers. I've done 30-40 procedural sedation cases in the ED without having to do anything more than a jaw thrust to open the airway. It is an excellent medication for reducing dislocations and fractures, pinning a tibia, repairing a small laceration (peds pt obviously), intubating, draining a perianal abscess or a bartholin's cyst abscess etc. It's even a useful anti-epileptic in status patients (although it is usually followed by an endotracheal tube.)

The reason propofol is so much more useful than fentanyl/versed is that the effects are much more reliable, and the half-life is so much shorter. Doing a propofol sedation doesn't tie up a room or a nurse nearly as long as using versed.

The moment that a hospital anesthesia department makes its staff available 24-7 to do brief procedural sedations in the ED is the moment it can start claiming exclusive use of medications.

Don't get me wrong, anesthesiologists have an excellent set of skills, and generally take excellent care of their patients. And if some crazy surgeon takes me to the OR, you better believe I want a residency-trained, board-certified anesthesiologist making sure I come back out, but all anesthesia does not require an anesthesiologist.

By the way, good luck taking propofol away from the intensivists.

 

[jwk]

I disagree that an anesthesia residency in and of itself automatically makes it safe for one to be able to use a specific medication. As long as one is familiar with the dosing, effects, adverse reactions, and contraindications of the medicine, AND has the ability to mitigate its effects...i.e. manage an airway and hypotension, AND has the patient properly monitored (Cardiac monitor, continuous BP, Pulse ox, ETCO2) I think propofol can be very appropriately used by non-anesthesiologist providers. I've done 30-40 procedural sedation cases in the ED without having to do anything more than a jaw thrust to open the airway. It is an excellent medication for reducing dislocations and fractures, pinning a tibia, repairing a small laceration (peds pt obviously), intubating, draining a perianal abscess or a bartholin's cyst abscess etc. It's even a useful anti-epileptic in status patients (although it is usually followed by an endotracheal tube.)

The reason propofol is so much more useful than fentanyl/versed is that the effects are much more reliable, and the half-life is so much shorter. Doing a propofol sedation doesn't tie up a room or a nurse nearly as long as using versed.

The moment that a hospital anesthesia department makes its staff available 24-7 to do brief procedural sedations in the ED is the moment it can start claiming exclusive use of medications.

Don't get me wrong, anesthesiologists have an excellent set of skills, and generally take excellent care of their patients. And if some crazy surgeon takes me to the OR, you better believe I want a residency-trained, board-certified anesthesiologist making sure I come back out, but all anesthesia does not require an anesthesiologist.

By the way, good luck taking propofol away from the intensivists.

Propofol use in the ICU, by infusion on ventilated patients, is an entirely different set of circumstances.

In our institution, the use of anesthetic agents is restricted to use ONLY by anesthesia personnel. This includes propofol, thiopental, brevital, and ketamine. You want a cardioversion with propofol sedation? Ya gotta call us. Reduce a fracture or dislocation with propfol sedation? It's gonna be done by anesthesia in the OR.

Your comment demonstrates exactly why anesthesia folks are concerned about non-anesthesia providers giving propofol. "...I've done 30-40 procedural sedation cases in the ED without having to do anything more than a jaw thrust to open the airway..." At this point, you have crossed the line from conscious or even deep sedation to general anesthesia. Was your patient NPO? Doubtful - and foolish. Loss of protective airway reflexes is one of the things that define general anesthesia. And I'm curious - who else was there with you? Do you have an RN that does NOTHING but administer drugs and monitor the patient and has no other responsibilities?

"Brief procedural sedation" in the ER can be accomplished by other means. Propofol can certainly makes it easier in some cases, but it certainly isn't required. Good luck the first time you have a problem with it and your patient loses their airway and aspirates because they weren't NPO when they received a general anesthetic in the ER without someone from the anesthesia department being present. Even a marginal malpractice attorney is aware of that little warning on the package insert.

 

[AzMichelle]

I'm interested to know your opinions about something that has been happening in my hospital lately. While I am an ICU RN our Med/Surg floors are using Diprovan for terminal CA pts. If they were in ICU I could understand (purely for legal reasons), but they aren't. These are folks that the end is going to happen in hours/days.

To some it appears this is merely to speed up the death process (that may happen however, I don't agree that is the logic behind the practice). While I am not sure that is a horrible thing while looking at the total picture, what about liability and criminal legal issues? There is 1 nurse to 6-10 patients, depending on the floor.

Now, these are pts that Morphine doesn't touch and high dose intrathecal Fentanyl just make it appear they couldn't react to the pain. These people hurt like you don't see on a daily basis.

Thoughts?

 

[heartICU]

I'm interested to know your opinions about something that has been happening in my hospital lately. While I am an ICU RN our Med/Surg floors are using Diprovan for terminal CA pts. If they were in ICU I could understand (purely for legal reasons), but they aren't. These are folks that the end is going to happen in hours/days.

To some it appears this is merely to speed up the death process (that may happen however, I don't agree that is the logic behind the practice). While I am not sure that is a horrible thing while looking at the total picture, what about liability and criminal legal issues? There is 1 nurse to 6-10 patients, depending on the floor.

Now, these are pts that Morphine doesn't touch and high dose intrathecal Fentanyl just make it appear they couldn't react to the pain. These people hurt like you don't see on a daily basis.

Thoughts?

I am not attacking you, but there are several problems with what is happening at your facility. First of all, propofol has no analgesic properties. So starting it on patients with cancer pain is almost cruel - it makes it look as if the patient is having no pain, but all it is doing is preventing them from reacting. So it may look to some as if it has analgesic properties, but it does not.

If it is used to speed up the death process - that is a whole other (illegal) issue.

Second, on a med-surg floor?? No med-surg RN should be administering propofol, no matter what the circumstance, for several reasons. The med-surg RN probably has at least six other patients in different rooms, right? So there is no one there to keep a constant eye on the patient. Unless that patient is trached, you don't have a secure airway. The difference between spontaneous respirations and apnea with propofol can often be just a drop or two - that is why it is SO dangerous when used by people who cannot secure an airway.

If these patients' pain cannot be managed by morphine or fentanyl, there are other drugs and techniques that can be used. Do you have a pain management practice at your institution? I would get them involved and allow them some input on appropriate management of cancer pain. Propofol is a terrible drug for pain management, because it does not manage pain.

What doses are these patients being given? Not that it matters, but I am just curious. Who is writing the orders for propofol?

 

[AzMichelle]

I am not attacking you, but there are several problems with what is happening at your facility. First of all, propofol has no analgesic properties. So starting it on patients with cancer pain is almost cruel - it makes it look as if the patient is having no pain, but all it is doing is preventing them from reacting. So it may look to some as if it has analgesic properties, but it does not.

If it is used to speed up the death process - that is a whole other (illegal) issue.

Second, on a med-surg floor?? No med-surg RN should be administering propofol, no matter what the circumstance, for several reasons. The med-surg RN probably has at least six other patients in different rooms, right? So there is no one there to keep a constant eye on the patient. Unless that patient is trached, you don't have a secure airway. The difference between spontaneous respirations and apnea with propofol can often be just a drop or two - that is why it is SO dangerous when used by people who cannot secure an airway.

If these patients' pain cannot be managed by morphine or fentanyl, there are other drugs and techniques that can be used. Do you have a pain management practice at your institution? I would get them involved and allow them some input on appropriate management of cancer pain. Propofol is a terrible drug for pain management, because it does not manage pain.

What doses are these patients being given? Not that it matters, but I am just curious. Who is writing the orders for propofol?

Oh, I know you aren't attacking. Besides, I'm not advocating the practice but instead I am quite against it.

I realize Diprovan doesn't cut the pain, it is given with Fentanyl (usually a drip) and it is the Fentanyl that isn't working. Call it a dosing issue or what have you, it isn't working and the docs don't write different orders. I agree a med/surg nurse should not be touching the stuff. I completely agree, thus my question here. I was beginning to wonder if I missed some new info on the drug. The Med/Surg RN doesn't have 6 patients, s/he has 6-10 patients and no, no trach.

Being that I'm not a Med/Surg nurse, I can't really get anyone else involved. I'd love to, but I can't. Personally, I wouldn't touch those patients for the world, but there are stupid stupid nurses out there that will do any 'ol thing they are told like a good little puppy.

Honestly, I don't know the dose since I wasn't caring for the patients, however I did ask who wrote the orders and it was the Oncologist.

Creepy, eh? For the life of me I can't figure out how there are no lawsuits.

 

[AzMichelle]

Clarification...

When intrathecal Fentanyl doesn't work then the orders were changed to Diprovan and IV Fentanyl.

 

[2ndyear]

Propofol on the floor for sedation is just too much in my opinion, and it's not the nurses to blame but the ordering physician. Especially when dexemetomidate is available and does not suppress respiratory drive or airway reflexes. A recent Anesthesiology article dealt with using Precedex in extubation for removal of life support. Seems like a nice, humane way to sedate someone. You still have to control their pain, but this is another issue altogether.

The move to change the FDA labeling by the GI physicians is disheartening because it isn't motivated by what's best for the patient, but by finances. The anesthesia fee by Medicare (and hence many private insurers) is included in the procedure fee for endoscopies. Having to take this fee out leaves them with less in their pocket. I have to say that I looked over their argument, and the literature is in their favor. The studies are there. Most were on ASA I/II patients with a couple of III's thrown in, however. Maybe your average 40 yo colonoscopy, but surely not the old GI bleeder that you want to scope in the middle of the night emergently. Rescuing respiratory depression isn't that hard with basic skills. Managing the person with an EF of 10% after you've cranked up the propofol into the deep sedation range will be an issue. You can't teach hemodynamics in a 2 day course on 'conscious' sedation.

I'm not quite sure of the ramifications if the label does change. What other procedures will be affected? I can see pulmonologists using it for bronchs, but we're not there now anyways. Will cardiologists push for their own propofol in the EP lab? I'm not sure how this one is billed, ie, are we taking part of their set cath or ICD implant fee? Same goes for IR procedures. I can't see it changing operative anesthesia though. There's no advantage to the surgeons not having a member of the anesthesia team present that I can see, financial or otherwise.

 

[nedflanders]

In our institution, it's obvious to see how little our non-anesthesia colleagues know and understand about Propofol. They think of it as a magic drug that is extremely easy to use - you turn it on and the patient shouldn't move. This however it definitely not the case. It may look easy based on the ease and experience of an anesthesiologist - careful to titrate and watch for specific respiratory signs and vigilant monitoring. Anesthesia should be administered by qualified individuals and deep sedation with propofol is anesthesia. Sedation in the ICU while on a ventilator that is supporting a patient's airway is a completely different story and an ICU doctor can use Propofol for this use without anesthesia personnel. What's next - OB/GYN offices having D&C's rooms outside an OR performing MAC anesthesia with Propofol doing a D&C? Anesthesiologist's should fight to maintain the warning on Propofol not only for the income - a lot of income is made doing quick MAC cases - but for the patient's safety. The contiuum of MAC anesthesia to GA can often be extremely short and I think all of us on this forum can agree that only qualified individuals perform anesthsia.

 

[AzMichelle]

Propofol on the floor for sedation is just too much in my opinion, and it's not the nurses to blame but the ordering physician. Especially when dexemetomidate is available and does not suppress respiratory drive or airway reflexes. A recent Anesthesiology article dealt with using Precedex in extubation for removal of life support. Seems like a nice, humane way to sedate someone. You still have to control their pain, but this is another issue altogether.

While I agree that it is too much for a Med/Surg nurse to handle it IS the nurse to blame as well as the ordering doc. She doesn't have to be a good doobie and do everything she is told. When the pt's welfare is at issue it is okay to question the orders and push the issue if need be. Actually, it is her job. If she doesn't know how dangerous a drug is, she shouldn't be giving it until she educates herself.

When a new drug comes out that I am not familiar with I'm not about to give it until I either read up on it or I'm on the phone to pharmacy. That's just not asking too much of a nurse.

 

[TXANESTHETIST]

I disagree that an anesthesia residency in and of itself automatically makes it safe for one to be able to use a specific medication. As long as one is familiar with the dosing, effects, adverse reactions, and contraindications of the medicine, AND has the ability to mitigate its effects...i.e. manage an airway and hypotension, AND has the patient properly monitored (Cardiac monitor, continuous BP, Pulse ox, ETCO2) I think propofol can be very appropriately used by non-anesthesiologist providers. I've done 30-40 procedural sedation cases in the ED without having to do anything more than a jaw thrust to open the airway. It is an excellent medication for reducing dislocations and fractures, pinning a tibia, repairing a small laceration (peds pt obviously), intubating, draining a perianal abscess or a bartholin's cyst abscess etc. It's even a useful anti-epileptic in status patients (although it is usually followed by an endotracheal tube.)

The reason propofol is so much more useful than fentanyl/versed is that the effects are much more reliable, and the half-life is so much shorter. Doing a propofol sedation doesn't tie up a room or a nurse nearly as long as using versed.

The moment that a hospital anesthesia department makes its staff available 24-7 to do brief procedural sedations in the ED is the moment it can start claiming exclusive use of medications.

Don't get me wrong, anesthesiologists have an excellent set of skills, and generally take excellent care of their patients. And if some crazy surgeon takes me to the OR, you better believe I want a residency-trained, board-certified anesthesiologist making sure I come back out, but all anesthesia does not require an anesthesiologist.

By the way, good luck taking propofol away from the intensivists.

Like someone previously stated, use by intensiveist and ICU WITH A PROTECTED AIRWAY (intubated only) is a different story. I think the problem is GI docs or any other personnel who are using it without a protected airway who are not airway management experts.

The whole cancer thing is rediculous! Big ethical issue. It is not at all an analgesic and will hasten death if not monitored because it can knock out respiratory drive all together. If I were a nurse on that floor I would flat out refuse to give this to my patients. I would also check with risk management with the hospital. That would be a field day for a lawyer!

 

[redstorm]

I disagree that an anesthesia residency in and of itself automatically makes it safe for one to be able to use a specific medication. As long as one is familiar with the dosing, effects, adverse reactions, and contraindications of the medicine, AND has the ability to mitigate its effects...i.e. manage an airway and hypotension, AND has the patient properly monitored (Cardiac monitor, continuous BP, Pulse ox, ETCO2) I think propofol can be very appropriately used by non-anesthesiologist providers. I've done 30-40 procedural sedation cases in the ED without having to do anything more than a jaw thrust to open the airway. It is an excellent medication for reducing dislocations and fractures, pinning a tibia, repairing a small laceration (peds pt obviously), intubating, draining a perianal abscess or a bartholin's cyst abscess etc. It's even a useful anti-epileptic in status patients (although it is usually followed by an endotracheal tube.)

The reason propofol is so much more useful than fentanyl/versed is that the effects are much more reliable, and the half-life is so much shorter. Doing a propofol sedation doesn't tie up a room or a nurse nearly as long as using versed.

The moment that a hospital anesthesia department makes its staff available 24-7 to do brief procedural sedations in the ED is the moment it can start claiming exclusive use of medications.

Don't get me wrong, anesthesiologists have an excellent set of skills, and generally take excellent care of their patients. And if some crazy surgeon takes me to the OR, you better believe I want a residency-trained, board-certified anesthesiologist making sure I come back out, but all anesthesia does not require an anesthesiologist.

By the way, good luck taking propofol away from the intensivists.

excellent post!!.. Yes i agree with you completely. ER docs prob the only other docs who understand how to use propofol and what to do if you use too much of it.. or the patient has a respiratory event and needs mask ventilation and/or intubation. BUt I see too many docs taking chances with the stuff.. just bolusing it without monitors or even supplemental oxygen.. That is not the proper way of using propofol.. and sometimes.. if the patient is still agitated.. the answer is not to give more PROPOFOL instinctively.. sometimes the agitation is caused by propofol and the patient is hypoxic.. Things to consider..

midaz and fentanyl, and propofol are 2 different kinds of sedation.. the former is more elegant,, and you can get pretty deep with that.. propofol is more hypnotic.. airway obstructs type of sedation

 

[beezar]

Propofol use in the ICU, by infusion on ventilated patients, is an entirely different set of circumstances.

In our institution, the use of anesthetic agents is restricted to use ONLY by anesthesia personnel. This includes propofol, thiopental, brevital, and ketamine. You want a cardioversion with propofol sedation? Ya gotta call us. Reduce a fracture or dislocation with propfol sedation? It's gonna be done by anesthesia in the OR.

Your comment demonstrates exactly why anesthesia folks are concerned about non-anesthesia providers giving propofol. "...I've done 30-40 procedural sedation cases in the ED without having to do anything more than a jaw thrust to open the airway..." At this point, you have crossed the line from conscious or even deep sedation to general anesthesia. Was your patient NPO? Doubtful - and foolish. Loss of protective airway reflexes is one of the things that define general anesthesia. And I'm curious - who else was there with you? Do you have an RN that does NOTHING but administer drugs and monitor the patient and has no other responsibilities?

"Brief procedural sedation" in the ER can be accomplished by other means. Propofol can certainly makes it easier in some cases, but it certainly isn't required. Good luck the first time you have a problem with it and your patient loses their airway and aspirates because they weren't NPO when they received a general anesthetic in the ER without someone from the anesthesia department being present. Even a marginal malpractice attorney is aware of that little warning on the package insert.

Completely agree with jwk. At our institution, ER docs routinely use propofol for procedures on pts who are not NPO. While the most of the time nothing will happen, if you do enough of these, someone will aspirate... and if it's a large amt of particulate matter, morbidiy/mortality is very high... all because they wanted to reduce someone's dislocated shoulder.

 

[The White Coat Investor]

"Was your patient NPO? Doubtful - and foolish."

Not necessarily. See this article:

Preprocedural fasting state and adverse events in children undergoing procedural sedation and analgesia in a pediatric emergency department.

Agrawal D, Manzi SF, Gupta R, Krauss B.

Division of Emergency Medicine, Children's Hospital Boston and Harvard Medical School, Boston, MA, USA. [email protected]

STUDY OBJECTIVE: Assessment of preprocedural fasting is considered essential in minimizing the risks of procedural sedation and analgesia. Established fasting guidelines are difficult to follow in the emergency department (ED). We characterize the fasting status of patients receiving procedural sedation and analgesia in a pediatric ED and assess the relationship between fasting status and adverse events. METHODS: A prospective case series was conducted in a children's hospital ED during an 11-month period. All consecutive patients requiring procedural sedation and analgesia were included. Preprocedural fasting state and adverse events were recorded. The percentage of patients undergoing procedural sedation and analgesia who did not meet fasting guidelines was determined. Adverse events were analyzed in relation to fasting status. RESULTS: One thousand fourteen patients underwent procedural sedation and analgesia, and data on fasting status were available for 905 (89%) patients. Of these 905 patients, 509 (56%; 95% confidence interval [CI] 53% to 60%) did not meet fasting guidelines. Seventy-seven adverse events occurred in 68 (6.7%; 95% CI 5.2% to 8.4%) of the 1,014 patients. All adverse events were minor and successfully treated. Adverse events occurred in 32 (8.1%; 95% CI 5.6% to 11.2%) of 396 patients who met and 35 (6.9%; 95% CI 4.8% to 9.4%) of 509 patients who did not meet fasting guidelines. There was no significant difference in median fasting duration between patients with and without adverse events and between patients with and without emesis. Emesis occurred in 15 (1.5%) patients. There were no episodes of aspiration (1-sided 97.5% CI 0% to 0.4%). CONCLUSION: Fifty-six percent of children undergoing ED procedural sedation and analgesia were not fasted in accordance with established guidelines. There was no association between preprocedural fasting state and adverse events.

"Loss of protective airway reflexes is one of the things that define general anesthesia. And I'm curious - who else was there with you?"

Let's see, there is usually an orthopedic resident doing a reduction, my attending, and a dedicated nurse.

Do you have an RN that does NOTHING but administer drugs and monitor the patient and has no other responsibilities?

Yes. In fact, she records the doses of the medications I push and I monitor the patient. As a general rule, we have a physician separate from the one doing the procedure to do the sedation. Although a recent study suggests even this may be unnecessary.

"Brief procedural sedation" in the ER can be accomplished by other means..."

Sure, Versed, methohexital, ketamine, propofol, you name it....But look, the complication rate is the same:

Acad Emerg Med. 1999 Oct;6(10):989-97. Related Articles, Links

A clinical trial of propofol vs midazolam for procedural sedation in a pediatric emergency department.

Havel CJ Jr, Strait RT, Hennes H.

Department of Pediatrics, Medical College of Wisconsin, Milwaukee, USA. [email protected]

OBJECTIVE: To compare the effectiveness, recovery time from sedation, and complication rate of propofol with those of midazolam when used for procedural sedation in the pediatric emergency department (PED). METHODS: A prospective, blinded, randomized, clinical trial comparing propofol and midazolam was conducted in the PED of a tertiary pediatric center. Eligible patients were aged 2-18 years with isolated extremity injuries necessitating closed reduction. All patients received morphine for pain, then were randomized to receive propofol or midazolam for sedation. Vital signs, pulse oximetry, and sedation scores were recorded prior to sedation and every 5 minutes thereafter until recovery. Recovery time, time from cast completion to discharge, and other time intervals during the PED course and all sedation-related complications were also recorded. RESULTS: Between August 1996 and October 1997, 91 patients were enrolled. Demographic data, morphine doses, and sedation scores were similar between the propofol and midazolam groups. Mean +/- SD recovery time for the propofol group was 14.9+/-11.1 minutes, compared with 76.4+/-47.5 minutes for the midazolam group, p<0.001. Mild transient hypoxemia was the most significant complication, occurring in 5 of 43 (11.6%) patients given propofol and 5 of 46 (10.9%) patients given midazolam (odds ratio 1.08, 95% CI = 0.24 to 4.76). CONCLUSION: In this study, propofol induced sedation as effectively as midazolam but with a shorter recovery time. Complication rates for propofol and midazolam were comparable, though the small study population limits the power of this comparison. Propofol may be an appropriate agent for sedation in the PED; however, further study is necessary before routine use can be recommended.

Acad Emerg Med. 2003 Sep;10(9):931-7.
Randomized clinical trial of propofol versus methohexital for procedural sedation during fracture and dislocation reduction in the emergency department.

Miner JR, Biros M, Krieg S, Johnson C, Heegaard W, Plummer D.

Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN 55415, USA. [email protected]

Although methohexital has been well studied for use in emergency department (ED) procedural sedation (PS), propofol has been evaluated less extensively for ED use. OBJECTIVE: The authors hypothesized that there is no difference in the depth of sedation and the rate of respiratory depression (RD) between propofol and methohexital in PS during the reduction of fractures and dislocations in the ED. METHODS: This was a randomized prospective study of nonintoxicated adult patients undergoing PS for fracture or dislocation reduction in the ED between July 2001 and March 2002. Patients were randomized to receive either propofol or methohexital, 1 mg/kg intravenously, followed by repeat boluses of 0.5 mg/kg every 2 minutes until adequate sedation was achieved. Doses, vital signs, end-tidal CO(2) (ETCO(2)) by nasal cannulae, pulse oximetry, and bispectral electroencephalogram analysis (BIS) scores were recorded. RD was defined as an ETCO(2) greater than 50 torr, an oxygen saturation less than 90% at any time, or an absent ETCO(2) waveform. After returning to baseline mental status, patients completed three 100-mm visual analog scales (VASs) regarding pain associated with the procedure, recall of the procedure, and satisfaction. RD rates and VAS outcomes were compared with chi-square tests. RESULTS: There were 109 patients enrolled; six were excluded for study protocol violations. Of the remaining 103 patients, 52 received methohexital (reduction successful in 94%) and 51 received propofol (98% successful). No cardiac rhythm abnormalities or significant decline in systolic blood pressure (>20%) was detected. Six patients required bag-valve-mask-assisted ventilations during the procedure, all for less than 1 minute; four of these patients received methohexital, and two received propofol. By the authors' definition, RD was seen in 25 of 52 (48%) patients receiving methohexital and 25 of 51 (49%) patients receiving propofol (p = 0.88). The mean minimum recorded BIS score was 66.2 (95% confidence interval [CI] = 62 to 70) for methohexital and 66 (95% CI = 60 to 71) for propofol. VAS results showed similar rates of reported pain, recall, and satisfaction for the two agents. CONCLUSIONS: The authors were unable to detect a significant difference in the level of subclinical RD or the level of sedation by BIS between the two agents. The use of either agent seems to be safe in the ED.

 

[The White Coat Investor]

"Propofol can certainly makes it easier in some cases, but it certainly isn't required."

Nothing is required, but if something is easier, and JUST AS SAFE, it should be an option.

"Good luck the first time you have a problem with it and your patient loses their airway and aspirates because they weren't NPO when they received a general anesthetic in the ER without someone from the anesthesia department being present. Even a marginal malpractice attorney is aware of that little warning on the package insert."

Thank you for wishing me luck. By the way, emergency physicians get sued for missed MIs, missed appendicitis, missed fractures, and missed foreign bodies. I'm not sure there has EVER been a case where an EP was successfully sued secondary to experiencing the complication of aspiration during an ED procedural sedation. Let me know if you hear of one.

Below are a handful of articles I found in a 1 minute PUBMED search on propofol and ED procedural sedation. You will notice a common theme: mortality is nil, morbidity is minimal, complications are hypotension, hypoxia, and apnea, intubation is rare, and aspiration is non-existent.

Am J Emerg Med. 2005 Mar;23(2):190-5. Related Articles, Links

Propofol for deep procedural sedation in the ED.

Frazee BW, Park RS, Lowery D, Baire M.

Department of Emergency Medicine, Alameda County Medical Center-Highland Campus, Oakland, CA 94602, USA.

We sought to evaluate the use of propofol (2,6-diisopropylphenol) for ED procedural sedation, particularly when administered in a routine fashion for a variety of indications. METHODS: This was a prospective observational study conducted in an urban teaching ED. Propofol was administered by handheld syringe and combined with fentanyl. Measurements included propofol and fentanyl dose, serial vital signs, pulse oximetry, adverse events, and patient and physician satisfaction. RESULTS: One hundred thirty-six subjects (18 to 69 years) were enrolled. Procedures included 82 (60.3%) abscess incision and drainages and 47 (34.6%) orthopedic reductions. Adverse events occurred in 14 cases (10.3%; 95% confidence interval 5.2% to 15.4%), including hypotension in 5, hypoxemia in 7, and apnea in 5. One patient required intubation. Both patient and physician satisfaction were excellent. CONCLUSIONS: ED procedural sedation with propofol was effective and well accepted by patients and physicians. However, it produced a significant incidence of hypotension, hypoxemia, and apnea.



Ann Emerg Med. 2003 Dec;42(6):773-82. Related Articles, Links

Propofol for procedural sedation in children in the emergency department.

Bassett KE, Anderson JL, Pribble CG, Guenther E.

Division of Pediatric Emergency Medicine, Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City 84102, USA. [email protected]

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 (<or=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.


J Emerg Med. 2004 Jul;27(1):11-4. Related Articles, Links


Propofol for procedural sedation in the pediatric emergency department.

Pershad J, Godambe SA.

Division of Critical Care & Emergency Services, Department of Pediatrics, LeBonheur Children's Medical Center, 50 N. Dunlap Street, Memphis, TN 38103, USA.

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.

Crit Care Med. 2002 Jun;30(6):1231-6. Related Articles, Links

Is propofol safe for procedural sedation in children? A prospective evaluation of propofol versus ketamine in pediatric critical care.

Vardi A, Salem Y, Padeh S, Paret G, Barzilay Z.

Department of Pediatric Intensive Care, Chaim Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel.

OBJECTIVES: To compare propofol with ketamine sedation delivered by pediatric intensivists during painful procedures in the pediatric critical care department (PCCD). DESIGN: Prospective 15-month study. SETTING: An 18-bed multidisciplinary, university-affiliated PCCD. INTERVENTIONS: All children were randomized to the propofol or ketamine protocol according to prescheduled procedure dates. Propofol was delivered by continuous infusion after a loading bolus dose and a minidose of lidocaine (PL). Ketamine was given as a bolus injection together with midazolam and fentanyl (KMF). Repeated bolus doses of both drugs were given to achieve the desired level of anesthesia. The studied variables included procedures performed, anesthetic drug doses, procedure and recovery durations, and side effect occurrence. The patient's parents, PCCD nurse and resident physician, pediatric intensivist, and the physician performing the procedure graded the adequacy of anesthesia. MEASUREMENTS AND MAIN RESULTS: Of the 105 procedures in 98 children, PL sedation was used in 58 procedures, and KMF was used in 47. Recovery time was 23 mins for PL and 50 mins for KMF, and total PCCD monitoring was 43 mins for PL and 70 mins for KMF. Five children (10.6%) in the KMF group and in none in the PL group experienced discomfort during emergence from sedation. Transient decreases in blood pressure, partial airway obstruction, and apnea were more frequent in the PL than in the KMF sedation. All procedures were successfully completed, and no child recalled undergoing the procedure. The overall sedation adequacy score was 97% for PL and 92% for KMF (p <.05). CONCLUSIONS: Both PL and KMF anesthesia are effective in optimizing comfort in children undergoing painful procedures. PL scored better by all evaluators, recovery from PL anesthesia after procedural sedation was more rapid, total PCCD stay was shorter with PL, and emergence from PL was smoother than with KMF. Because transient respiratory depression and hypotension are associated with PL, it is considered safe only in a monitored environment (e.g., a PCCD).

P.S. I do agree propofol sedation in intubated ICU patients is a different matter entirely. But the OP did suggest "Propofol use by non-anesthesia trained providers is a bad idea," so I decided to mention at least two different areas of medicine where I think propofol use is acceptable by non-anesthesia residency trained physicians. 1) EDs and 2) ICUs
Several posters above mentioned instances where propofol was used as a sedative on the floor and where propofol sedation was done without monitoring....both obviously unacceptable given propofol's pharmacologic profile.

 

[The White Coat Investor]

In our institution, the use of anesthetic agents is restricted to use ONLY by anesthesia personnel. This includes propofol, thiopental, brevital, and ketamine. You want a cardioversion with propofol sedation? Ya gotta call us. Reduce a fracture or dislocation with propfol sedation? It's gonna be done by anesthesia in the OR.

Be sure to tell everyone where you work so we can avoid it! You guys tie up an OR just to reduce a shoulder? IMHO that's overkill. Or are people pretending that fentanyl/versed is safe to use in the ED but propofol isn't? See the article posted above comparing safety.

I submit that doing a procedural sedation in an OR where a dedicated anesthesiologist is monitoring the airway, the patient is attached to full monitoring (including end-tidal CO2), and airway management equipment is at hand is no safer than doing a procedural sedation in an ED where a dedicated emergency physician is monitoring the airway, the patient is attached to full monitoring (including end-tidal CO2), and airway management equipment is at hand. I suggest anyone making that claim find some data supporting their position, because I could not. By the way, the data referenced by the link in the OP refers only to studies done by gastroenterologists.

 

[DrDre']

There is a huge difference, in my mind, between an EM doc or anesthesiologist providing propofol and other providers. Both of the above actually know the ABCs intimately and know how to recognize and deal with an emergency.

I have not seen prop used yet by other providers. I have seen versed and meperidine used by pulmonologists. I think it is a bad idea, already. Although as intensivists, they know how to deal with stuff going bad, they are not intensivists when they bronch, they are technicians. they are NOT paying attn to the patient, no matter what they say. And the RN may not be either.
A dedicated propofol provider is the KEY.
Desperado, great use of your mind! Nice to see that than typical SDN yelling and screaming 🙂!

 

[Noyac]

I'm afraid that this is coming no matter what we do and we need to be proactive in the use of propofol by non-anesthesia providers. Here at my hosp. the anesthesia dept. is assisting in the credentialling process of these non-anesth. providers in the use of propofol and more importantly conscious sedation. We are focusing on airway management skills. There is a lack of knowledge out there and this is not going to stop them, so we need to educate. Just the other day a non-anesth provider was giving conscious sedation to a pt. with versed and fentanyl. When the pt. experienced resp. depression (no longer conscious sedation) the provider gave romazicon. There is a lot of educating that needs to be done. We as anesthesia can not be everywhere all the time nor do we really want to be there. These providers are not going to wait for us to schedule everything. And honestly, do we even need to be there for ASA 1 & 2 pts.? This is debateable.

 

[AJM]

I have not seen prop used yet by other providers. I have seen versed and meperidine used by pulmonologists. I think it is a bad idea, already. Although as intensivists, they know how to deal with stuff going bad, they are not intensivists when they bronch, they are technicians. they are NOT paying attn to the patient, no matter what they say. And the RN may not be either.

While I understand your concern, I respectfully disagree with your assessment of patient monitoring that takes place during bronchs. As a pulmonary fellow, I use versed and fentanyl all the time, and the patients are monitored quite well while they are sedated. It's very true that during the bronch I have absolutely no idea what's going on with the patient -- I would never claim that I am paying attention to anything other than the tracheobronchial anatomy. BUT, we always have a respiratory therapist and an RN in the room at all times. The RT assists during the bronch, and the RN's role is solely to monitor the patient and deliver medications. I rely on the RN to inform me if the patient's status starts to change so that we can react and deal with the problem quickly. (oh yeah - we also always have an attending in the room who doesn't really have any specific role -- but I know that this isn't the case in the real world, though). The system seems to work well, and we haven't been shut down yet. 🙂 Actually, we model our bronch staffing after the hospital's conscious sedation guidelines, and those of us who deliver conscious sedation have to take a training course taught by some of the anesthesia attendings at our program. I have not found any evidence that this kind of conscious sedation setup in a highly monitored environment is less safe than conscious sedation provided by an anesthesiologist -- but I'd be happy to hear about any studies that have shown otherwise.

As far as the propofol issue, even though we were taught to use it as part of our conscious sedation course, as a non-anesthesiologist I would not feel comfortable giving it as conscious sedation, mostly because I have very little experience with it. For a procedure such as a bronch or an endoscopy, which typically take longer than a shoulder reduction in the ED, it would be more appropriate to electively intubate the patient if propofol use is planned. Again, for a bronch in this kind of scenario, an anesthesiologist would probably not need to be there, as we will usually do a fiberoptic intubation at the beginning of the bronch. (A colo, EGD, or ERCP is a whole other story, though, IMO).

I do have to say that it's been interesting to hear my anesthesia colleagues' opinions on this issue in this thread....
Okay, I'm ready to stand in front of the firing line now for my ignorant comments... flame away 🙂

 

[beezar]

Pulmonary aspiration occurs in 1 in every 2000-3000 pts undergoing a general anesthetic (higher incidence in OB pts). Granted that general anesthesia (with either a ETT or LMA or whatever) is very different than ED procedural sedation, and that fasting guidelines are generally followed prior to general anesthesia... however, it would seem that all the studies you have quoted are significantly underpowered to detect aspiration incidence during ED procedural sedation. A study involving a much much higher number of pts is needed to accurately assess the incidence and morbidity/mortality of pulmonary aspiration during these procedures.

That being said, I think ER docs are certainly capable of giving propofol and managing the consequences of respiratory depression / hemodynamic instability. It's the other medical personnel that I'm worried about. How many times have you gone to a code to see RT's and RN's trying to mask ventilate pts completely ineffectively and not realize how ineffective they are?

Although I was called to a code where a pedi ER attending was giving "conscious sedation" and the pt stopped breathing for who knows how long and the sats went down to 21%... the first person to notice was the orthopod... and instead of mask ventilation, the ER attending panicked and was frantically trying to look up the drugs that reverse the effects of narcotics and benzos... now granted, this attending is not at all indicative of ER docs in general, but still a scary thought nevertheless.

 

[Orchard]

I submit that doing a procedural sedation in an OR where a dedicated anesthesiologist is monitoring the airway, the patient is attached to full monitoring (including end-tidal CO2), and airway management equipment is at hand is no safer than doing a procedural sedation in an ED where a dedicated emergency physician is monitoring the airway, the patient is attached to full monitoring (including end-tidal CO2), and airway management equipment is at hand.

I submit that you are a GOD D A M N IDIOT!

 

[The White Coat Investor]

Pulmonary aspiration occurs in 1 in every 2000-3000 pts undergoing a general anesthetic (higher incidence in OB pts). Granted that general anesthesia (with either a ETT or LMA or whatever) is very different than ED procedural sedation, and that fasting guidelines are generally followed prior to general anesthesia... however, it would seem that all the studies you have quoted are significantly underpowered to detect aspiration incidence during ED procedural sedation.

A valid criticism. Nonetheless, the fact remains that most of the patients for whom I do procedural sedation cannot realistically wait 8 hours for their pizza and beer to be digested. It is no different than an emergent patient in the OR. You have to do the case NOW, so you do the best you can. There is a lower chance of aspiration during procedural sedation than during intubation for an emergent case, simply because we're not screwing around in the airway/pharynx inducing vomiting, but it remains possible that the incidence is higher than these studies would seem to indicate.

How many times have you gone to a code to see RT's and RN's trying to mask ventilate pts completely ineffectively and not realize how ineffective they are?

LMAO, so true, so true.

 

[The White Coat Investor]

I submit that you are a GOD D A M N IDIOT!

Nothing like a constructive discussion, is there. I look forward to working with you in the future.

 

[Orchard]

Nothing like a constructive discussion, is there. I look forward to working with you in the future.

Won't happen....I only work with professionals, which you clearly are not. 🙂

 

[DrDre']

Actually, although we may disagree with desperado, he has been very well behaved. Has cited a ton of research instead of just doing the SDN spoutin off thang.

You are new and just trashed him!

 

[Orchard]

You are new and just trashed him!

I trashed him for good reason. Carefully read what he posted:

"I submit that doing a procedural sedation in an OR where a dedicated anesthesiologist is monitoring the airway, the patient is attached to full monitoring (including end-tidal CO2), and airway management equipment is at hand is no safer than doing a procedural sedation in an ED where a dedicated emergency physician is monitoring the airway, the patient is attached to full monitoring (including end-tidal CO2), and airway management equipment is at hand."


What an inane statement to make; I guess I just wasted 4 years of my life doing an anesthesiology residency. Desperado is saying that an anesthesiologist is unneccesary since an ER doc can do a procedural sedation just as well in the ED. Well, let me ask you a question:

If your 4 year old child fractured their ulna, would you allow an ER doc to provide "procedural sedation" while the fracture was reduced? What if the line from conscious sedation to general anesthesia was crossed? Is this the best scenario to resucitate your child? What if, due to the pain of the procedure, your beloved child suddenly went into laryngospasm? Are you confident that, as Desperado purports, your child will be just as safe and have just as good an outcome? Please.......Don't dare ever denigrate my profession and training by impying that it could be relegated to someone with INFINITELY less experience in the above mentioned scenario. Ask yourself this question: If it were your child, what would you do? Anesthesiologist or ER doc?

 

[toofache32]

Not that this fire isn't burning hot enough already....but what about the dentists who use propofol daily in their sedations for surgical procedures?

 

[jwk]

Not that this fire isn't burning hot enough already....but what about the dentists who use propofol daily in their sedations for surgical procedures?

Even worse - should never happen. Most of the dentists I know are scared to even use nitrous.

 

[Xclamp]

I trashed him for good reason. Carefully read what he posted:

"I submit that doing a procedural sedation in an OR where a dedicated anesthesiologist is monitoring the airway, the patient is attached to full monitoring (including end-tidal CO2), and airway management equipment is at hand is no safer than doing a procedural sedation in an ED where a dedicated emergency physician is monitoring the airway, the patient is attached to full monitoring (including end-tidal CO2), and airway management equipment is at hand."


What an inane statement to make; I guess I just wasted 4 years of my life doing an anesthesiology residency. Desperado is saying that an anesthesiologist is unneccesary since an ER doc can do a procedural sedation just as well in the ED. Well, let me ask you a question:

If your 4 year old child fractured their ulna, would you allow an ER doc to provide "procedural sedation" while the fracture was reduced? What if the line from conscious sedation to general anesthesia was crossed? Is this the best scenario to resucitate your child? What if, due to the pain of the procedure, your beloved child suddenly went into laryngospasm? Are you confident that, as Desperado purports, your child will be just as safe and have just as good an outcome? Please.......Don't dare ever denigrate my profession and training by impying that it could be relegated to someone with INFINITELY less experience in the above mentioned scenario. Ask yourself this question: If it were your child, what would you do? Anesthesiologist or ER doc?

Right on brother... 👍
The fact is using propofol in the unit on a post-op CABG who is intubated and on an infusion at 40 mcg/kg/min is one thing, but giving grandma a slug of propofol in the ER at 1mg/kg with undiagnosed critical AS to reduce a fracture is a horse of a different color. Good luck with the chest compressions!
I am not trying to be an ***hole, but it is how propofol is used and who it is used by that is issue. Unless you are a resuscitation master, BUYER BE-WARE.

 

[DrDre']

Orchard, I agree with you. I just didn't think you needed to be quite so colorful...


As someone who resuscitated a 4 y o at the oral surgeons from cardiac arrest, I am against providers without "adequate" training using conscious sedation. The DMD gave PO ativan, then IM ketamine, then IV brevital, then sux x 2when he thought there was laryngospasm. Never did establish an airway.
The kid died 3 days later.


Too many people want to do procedures they are not adequately trained for...

 

[rn29306]

Orchard, I agree with you. I just didn't think you needed to be quite so colorful...


As someone who resuscitated a 4 y o at the oral surgeons from cardiac arrest, I am against providers without "adequate" training using conscious sedation. The DMD gave PO ativan, then IM ketamine, then IV brevital, then sux x 2when he thought there was laryngospasm. Never did establish an airway.
The kid died 3 days later.


Too many people want to do procedures they are not adequately trained for...

Quote from Friday the movie: "DAAAAAAAMMMMMNNNN". Hope he loses his ass in court.

 

[toofache32]

...As someone who resuscitated a 4 y o at the oral surgeons from cardiac arrest, I am against providers without "adequate" training using conscious sedation....

I somehow knew this would get this sort of response. How often does this happen? Especially compared with anesthesiologists? This is a trick question. While we're quoting the literature:

Perrott DH. Yuen JP. Andresen RV. Dodson TB. Office-based ambulatory anesthesia: outcomes of clinical practice of oral and maxillofacial surgeons. Journal of Oral & Maxillofacial Surgery. 61(9):983-95

PURPOSE: The delivery of office-based ambulatory anesthesia services is an integral component of the daily practice of oral and maxillofacial surgeons (OMSs). The purpose of this report was to provide an overview of current anesthetic practices of OMSs in the office-based ambulatory setting. MATERIALS AND METHODS: To address the research purpose, we used a prospective cohort study design and a sample composed of patients undergoing procedures in the office-based ambulatory setting of OMSs practicing in the United States who received local anesthesia (LA), conscious sedation (CS), or deep sedation/general anesthesia (DS/GA). The predictor variables were categorized as demographic, anesthetic technique, staffing, adverse events, and patient-oriented outcomes. Appropriate descriptive and bivariate statistics were computed as indicated. Statistical significance was set at < or =.05. RESULTS: The sample was composed of 34,191 patients, of whom 71.9% received DS/GA, 15.5% received CS, and 12.6% received LA. The complication rate was 1.3 per 100 cases, and the complications were minor and self-limiting. Two patients had complications requiring hospitalization. Most patients (80.3%) reported some degree of anxiety before the procedure. After the procedure, 61.2% of patients reported having no anxiety about future operations. Overall, 94.3% of patients reported satisfaction with the anesthetic, and more than 94.7% of all patients would recommend the anesthetic technique to a loved one. CONCLUSION: The findings of this study show that the office-based administration of LA, CS, or DS/GA delivered via OMS anesthesia teams was safe and associated with a high level of patient satisfaction.

I've got the article and several more if you want to see them. The overall safety has been demonstrated over and over.

 

[toofache32]

Quote from Friday the movie: "DAAAAAAAMMMMMNNNN". Hope he loses his ass in court.

Why? That's a pretty strong stance from someone who doesn't even know the details of the case (nor do I).

Ativan, Ketamine, and Brevital are the standards of practice that the vast majority of oral surgeons use. These standards were developed in conjunction with the ASA. Oral surgeons are the only "non-anesthesiologist" providers (that I am aware of) who have a specific and separate license to administer general anesthetics. The morbidity/mortality and adverse outcomes are unbelievably low, and have been for almost 100 years now. The study I quoted in the above post includes the morbidity experienced by some oral surgeons who were not following ASA-recommended monitoring guidelines, which happens in all specialties...I had an anesthesia attending who also didn't follow all the guidelines and he seemed to have more than his fair share of M&M presentations.

I wonder if this kid would have had a better outcome with an anesthesiologist. Maybe, but we can't tell from the info provided here or in the newspapers. I'm not defending this oral surgeon because he could have fouled up...my only point is that anecdotes do not equal data.

 

[bullard]

So 10/91 patients in this study were hypoxemic? And other patients had complications too? This is not a very impressive study -- I think it's more proof that propofol is a dangerous drug in untrained hands.

[email protected][/email]

OBJECTIVE: To compare the effectiveness, recovery time from sedation, and complication rate of propofol with those of midazolam when used for procedural sedation in the pediatric emergency department (PED). METHODS: A prospective, blinded, randomized, clinical trial comparing propofol and midazolam was conducted in the PED of a tertiary pediatric center. Eligible patients were aged 2-18 years with isolated extremity injuries necessitating closed reduction. All patients received morphine for pain, then were randomized to receive propofol or midazolam for sedation. Vital signs, pulse oximetry, and sedation scores were recorded prior to sedation and every 5 minutes thereafter until recovery. Recovery time, time from cast completion to discharge, and other time intervals during the PED course and all sedation-related complications were also recorded. RESULTS: Between August 1996 and October 1997, 91 patients were enrolled. Demographic data, morphine doses, and sedation scores were similar between the propofol and midazolam groups. Mean +/- SD recovery time for the propofol group was 14.9+/-11.1 minutes, compared with 76.4+/-47.5 minutes for the midazolam group, p<0.001. Mild transient hypoxemia was the most significant complication, occurring in 5 of 43 (11.6%) patients given propofol and 5 of 46 (10.9%) patients given midazolam (odds ratio 1.08, 95% CI = 0.24 to 4.76). CONCLUSION: In this study, propofol induced sedation as effectively as midazolam but with a shorter recovery time. Complication rates for propofol and midazolam were comparable, though the small study population limits the power of this comparison. Propofol may be an appropriate agent for sedation in the PED; however, further study is necessary before routine use can be recommended.

 

[bullard]

How can you have adverse events in 10% of patients and still conclude "ED procedural sedation with propofol was effective and well accepted by patients and physicians." That's optimism bordering on idiocy. Would you tolerate that kind of care from an anesthesiologist??


Am J Emerg Med. 2005 Mar;23(2):190-5. Related Articles, Links

Propofol for deep procedural sedation in the ED.

Frazee BW, Park RS, Lowery D, Baire M.

Department of Emergency Medicine, Alameda County Medical Center-Highland Campus, Oakland, CA 94602, USA.

We sought to evaluate the use of propofol (2,6-diisopropylphenol) for ED procedural sedation, particularly when administered in a routine fashion for a variety of indications. METHODS: This was a prospective observational study conducted in an urban teaching ED. Propofol was administered by handheld syringe and combined with fentanyl. Measurements included propofol and fentanyl dose, serial vital signs, pulse oximetry, adverse events, and patient and physician satisfaction. RESULTS: One hundred thirty-six subjects (18 to 69 years) were enrolled. Procedures included 82 (60.3%) abscess incision and drainages and 47 (34.6%) orthopedic reductions. Adverse events occurred in 14 cases (10.3%; 95% confidence interval 5.2% to 15.4%), including hypotension in 5, hypoxemia in 7, and apnea in 5. One patient required intubation. Both patient and physician satisfaction were excellent. CONCLUSIONS: ED procedural sedation with propofol was effective and well accepted by patients and physicians. However, it produced a significant incidence of hypotension, hypoxemia, and apnea.

 

[kailiedu]

You certainly posted many helpful information on propofol sedation in ED. I think it's important to look beyond the statistics or study. You, as an ED physician might be very comfortable doing a lot of procedures in your crowded, understaffed area (especially in large, government-based medical center). But comfortability and confidence do NOT equate to quality patient care.

Patient care is more than convenience, or legal-defensive medicine. It's about optimization and risk management when it's not an emergency.

Every physician, regardless of speciality should do the BEST to MINIMIZE any risk of intervention if there's a better, safer alternative (be it medication, procedure, or intervention-provider).

If you were the patient, would you rather have the whatever procedure done under propofol sedation given by trained airway specialist?

Personally, I would. Therefore, every patient of mine will deserve that.

Be sure to tell everyone where you work so we can avoid it! You guys tie up an OR just to reduce a shoulder? IMHO that's overkill. Or are people pretending that fentanyl/versed is safe to use in the ED but propofol isn't? See the article posted above comparing safety.

I submit that doing a procedural sedation in an OR where a dedicated anesthesiologist is monitoring the airway, the patient is attached to full monitoring (including end-tidal CO2), and airway management equipment is at hand is no safer than doing a procedural sedation in an ED where a dedicated emergency physician is monitoring the airway, the patient is attached to full monitoring (including end-tidal CO2), and airway management equipment is at hand. I suggest anyone making that claim find some data supporting their position, because I could not. By the way, the data referenced by the link in the OP refers only to studies done by gastroenterologists.

 

[bullard]

Would love to see the article -- my school doesn't have it online. Doesn't look obviously poor from the abstract like those emergency medicine articles...

I somehow knew this would get this sort of response. How often does this happen? Especially compared with anesthesiologists? This is a trick question:

Perrott DH. Yuen JP. Andresen RV. Dodson TB. Office-based ambulatory anesthesia: outcomes of clinical practice of oral and maxillofacial surgeons. Journal of Oral & Maxillofacial Surgery. 61(9):983-95

PURPOSE: The delivery of office-based ambulatory anesthesia services is an integral component of the daily practice of oral and maxillofacial surgeons (OMSs). The purpose of this report was to provide an overview of current anesthetic practices of OMSs in the office-based ambulatory setting. MATERIALS AND METHODS: To address the research purpose, we used a prospective cohort study design and a sample composed of patients undergoing procedures in the office-based ambulatory setting of OMSs practicing in the United States who received local anesthesia (LA), conscious sedation (CS), or deep sedation/general anesthesia (DS/GA). The predictor variables were categorized as demographic, anesthetic technique, staffing, adverse events, and patient-oriented outcomes. Appropriate descriptive and bivariate statistics were computed as indicated. Statistical significance was set at < or =.05. RESULTS: The sample was composed of 34,191 patients, of whom 71.9% received DS/GA, 15.5% received CS, and 12.6% received LA. The complication rate was 1.3 per 100 cases, and the complications were minor and self-limiting. Two patients had complications requiring hospitalization. Most patients (80.3%) reported some degree of anxiety before the procedure. After the procedure, 61.2% of patients reported having no anxiety about future operations. Overall, 94.3% of patients reported satisfaction with the anesthetic, and more than 94.7% of all patients would recommend the anesthetic technique to a loved one. CONCLUSION: The findings of this study show that the office-based administration of LA, CS, or DS/GA delivered via OMS anesthesia teams was safe and associated with a high level of patient satisfaction.

I've got the article and several more if you want to see them. The overall safety has been demonstrated over and over.

 

[toofache32]

Would love to see the article -- my school doesn't have it online. Doesn't look obviously poor from the abstract like those emergency medicine articles...

I tried to upload it but it's too large. PM me your email address and I'll send it. Same for anyone else here who's curious. It's a PDF file only about 125Kb.

I try to be objective....this is from the oral surgery literature so you have to be on the lookout for bias to really assess this critically. But I think it's a very well done article with a large patient pool in my humble opinion.

I hope you guys don't think I'm trying to stir up a $hit-storm here. Surgeon-delivered anesthesia has always been controversial to those outside our specialty. And it probably always will.

After spending all my time on Anesthesia, I have learned the most important aspect of our care...patient selection. Oral surgeons do almost entirely ASA 1 and 2 patients, the rest we turf out to the anesthesiologists. This is a double-whammy because this allows us to "better" our statistics while "worsening" the anesthesiologists' statistics because we are passing the inherently morbid patients to them. But I think that also demonstrates our ability to select patients carefully.

Even though our patients aren't typically "sick", we train with the same sicker ASA 3/4/5 patients as everyone else in the OR so we can always take things to the next level if necessary, including intubation (easily), general anesthesia, and ACLS. Our training is not the same as the General Surgery rotators who are just there to get intubation experience and then leave...we are there as the only anesthesia "resident" running the entire anesthetic.

Just out of curiousity....is anyone else here an anesthesia resident who sees the occasional oral surgery rotators? I had a really good time getting to know the anesthesia residents and faculty...definately the happiest and nicest people in the entire hospital.

 

[Noyac]

I wonder if this kid would have had a better outcome with an anesthesiologist. Maybe, but we can't tell from the info provided here or in the newspapers. I'm not defending this oral surgeon because he could have fouled up...my only point is that anecdotes do not equal data.

I guess we will never know now will we? But don't pretend to believe that the outcome wouldn't have been different if an anesthesiologist or CRNA or AA for that matter would have been involved in this childs care. You said that they only do ASA 1 and 2's and turf the others. Well I have to disagree that it hurts our numbers but yes it must help their numbers which apparently need the help if they are knocking off 4 yr olds. You got a lot to learn and you obviously aren't learning it fast enough on your rotation.

 

[toofache32]

...Well I have to disagree that it hurts our numbers but yes it must help their numbers which apparently need the help if they are knocking off 4 yr olds. You got a lot to learn and you obviously aren't learning it fast enough on your rotation.

It's good to know that a 4-year-old has never died under the care of an anesthesiologist. 😉 Nobody is saying we don't have morbidity, but our M&M is as about good as it gets. That's all. I'm only offering one possible exception to the original post with good literature and statistics. I'm the first to admit that you have to be careful with statistics...they're like a bikini: what they reveal isn't nearly as interesting as what they hide.

 

[DrDre']

Something that statistics and EBM inures us to- M & M. It becomes only a number or %.


If only one 3 yr old dies getting a tooth pulled per year. is that reasonable?


The case I know intimately would have done better with a paramedic. I believe he never opened her airway or else it would not have mattered she was apneic( and she would not have died of an anoxic brain injury after seizing for 3 days) . He could have ventilated her for as long as he wanted. My first field intubation, first urgent, first peds tube, first in front of a screaming mother (who had no idea what was going on!) and I get it 10 secs after getting my blade out.

He is still getting rich now, just has higher malpractice. This is classified as an anecdote- but it is a 1st person narrative. This guy did his training but was not solid. Worse, his ego prevented him from calling when he knew he needed help.

 

[jwk]

Getting back to the original post, I hope most of you anesthesia folks understand the impact this FDA change could have. Please take the time to let them know that propofol sedation by non-anesthesia providers is a BAD IDEA, and that there should be NO CHANGE IN LABELING OF PROPOFOL, that is, it should remain in the hands of anesthesia providers where it belongs.

Yeah, I know, you non-anesthesia guys will keep flaming. Be my guest. I've seen nothing in these posts or literature cites that would change my mind. 😴

 

[deleted6669]

jwk- I understand your concerns about propofol re: hypotension, etc
aside from fentanyl/versed what meds/combos are the anesthesia folks"really ok" with em using for conscious or procedural sedation? I use ketamine fairly often with kids and am comfortable with its use.use etomidate rarely. you guys don't have a problem with ketamine or etomidate, do you?
fyi- my preference when at all possible is to use hematoma blocks, regional blocks etc for procedures and I tend to only use bigger guns for behavioral issues.

 

[The White Coat Investor]

What an inane statement to make; I guess I just wasted 4 years of my life doing an anesthesiology residency. Desperado is saying that an anesthesiologist is unneccesary since an ER doc can do a procedural sedation just as well in the ED. Well, let me ask you a question:

If your 4 year old child fractured their ulna, would you allow an ER doc to provide "procedural sedation" while the fracture was reduced? What if the line from conscious sedation to general anesthesia was crossed? Is this the best scenario to resucitate your child? What if, due to the pain of the procedure, your beloved child suddenly went into laryngospasm? Are you confident that, as Desperado purports, your child will be just as safe and have just as good an outcome? Please.......Don't dare ever denigrate my profession and training by impying that it could be relegated to someone with INFINITELY less experience in the above mentioned scenario. Ask yourself this question: If it were your child, what would you do? Anesthesiologist or ER doc?

To reduce the fracture? Yes.

If the line was crossed? I would expect the airway to be controlled, and I would feel confident the emergency physician could take care of that.

If there was laryngospasm? I would expect my kid to be criched, and I would be glad that the person performing the sedation had the experience to perform a crich. How many of those did you do in residency, by the way?

I'm not denigrating your training, nor your profession any more than anesthesiologists have already done. There are cases which anesthesiologists feel are simple enough that they can be managed by someone who is not residency trained. (Nurse anesthetist, etc) Clearly, there are other cases which require the highest trained practitioner to perform. I would never consider performing anesthesia for a CABG or a thousand other cases which should properly be cared for a trained anesthesiologist. But a 5 minute sedation for an ulna reduction.....I'm not so sure you NEED an anesthesiologist to perform that safely.

Just as a surgeon is not needed to drain a simple abscess, so an anesthesiologist is not needed to perform a simple sedation.

As with most things in emergency medicine, we learn to do things that patients need because no one else will make themselves available to do them. That is why there is EP-performed ultrasound. That is why EPs intubate patients. That is why we run codes. That is why we do crichs, and chest tubes, and heaven forbid peri-mortem C-sections. No one else is waiting behind the ambulance bay door. We don't always claim to be the BEST person to do a certain procedure or see a certain patient. But we are the ones who are available 24-7, nights, weekends, and holidays, to be there. If a hospital's anesthesia group is willing to be available within an hour for every ED sedation, more power to them. I'd let them do all of them. It doesn't pay enough for the time required to be honest. But as long as kids are getting their arms reduced in the ED, and anesthesia continues to not be available to sedate them, you can be sure I will continue to do so. The alternative really isn't an EP vs an anesthesiologist. The alternative is an EP performed sedation versus no sedation at all. And given that choice with my kid, I'd take the EP.

 

[The White Coat Investor]

Getting back to the original post, I hope most of you anesthesia folks understand the impact this FDA change could have. Please take the time to let them know that propofol sedation by non-anesthesia providers is a BAD IDEA, and that there should be NO CHANGE IN LABELING OF PROPOFOL, that is, it should remain in the hands of anesthesia providers where it belongs.

Yeah, I know, you non-anesthesia guys will keep flaming. Be my guest. I've seen nothing in these posts or literature cites that would change my mind. 😴

By the way, labeling doesn't really affect anything. How many doctors use drugs for off-label uses? Consider the entire psychiatry profession guilty. If you really want to keep docs from using propofol, you should spend your time working with the hospital credentialing committee.

 

[The White Coat Investor]

So 10/91 patients in this study were hypoxemic? And other patients had complications too? This is not a very impressive study -- I think it's more proof that propofol is a dangerous drug in untrained hands.

Read the study before you criticize it. Here's a quote from the methods section:

There were no differences between the propofol and midazolam groups with respect to the incidence of other complications in the PED (Table 4). Hypoxemia was observed with similar frequencies between the propofol and midazolam groups. The lowest pulse oximeter reading recorded in any patient was 87%. All hypoxemic patients responded to verbal stimulation, supplemental oxygen via nasal cannula, and/or airway repositioning within 30 seconds. Oversedation occurred with similar frequencies in the two groups; however, the mean duration of oversedation was shorter in the propofol group (18.2 min, 95% CI = 10.2 to 26.2 vs 34.7 min, 95% CI = 26.3 to 47.1; p = 0.03). No study patient reached a level of sedation at any time at which he or she was unresponsive to pain. Mild agitation was noted during induction in 2 of 43 patients sedated with propofol; this resolved as sedation deepened. Agitation was more pronounced in patients sedated with midazolam (3 of 46), occurred during recovery, but also was self-limited

30 seconds.....
Lowest pulse ox was 87%.....
Not exactly overwhelming hypoxemia. Those other side effects you mention include such things as "pain with injection." News flash...propofol can burn a bit. No, the study isn't perfect. But the point is that no clinically significant effects occurred in this small study. The reason I included it was to show that propofol is AS safe in our hands as what you apparently are okay with us using to sedate patients.

 

[nedflanders]

If there was laryngospasm? I would expect my kid to be criched, and I would be glad that the person performing the sedation had the experience to perform a crich. How many of those did you do in residency, by the way?

There are many other appropriate ways to treat laryngospasm before going straight to a crich. Hence the reason why anesthesiologists are so concerned about propofol sedation used by non-anesthesiologists. We know how to treat the airway and avoid the crich. Great, a 4-year old with a crich, given sedation by an ED doctor whose label specifies use only by anesthesiologists that will be another million dollar victory for the trial lawyers.

BTW Although I haven't had to perform a crich during residency - thankfully there are other ways to manage the airway before preceding to that, we all know how to use the equipment and have practiced numerous times on mannequins.

 

[The White Coat Investor]

How can you have adverse events in 10% of patients and still conclude "ED procedural sedation with propofol was effective and well accepted by patients and physicians." That's optimism bordering on idiocy. Would you tolerate that kind of care from an anesthesiologist??
Am J Emerg Med. 2005 Mar;23(2):190-5. Related Articles, Links

Again, read the study. A quote from the methods section:

Medication doses, administration times, and total procedure time were recorded. Patient weights mostly were based on the patient's own estimate. All side effects and adverse reactions were recorded. Hypotension was defined as a drop in systolic blood pressure to less than 90 mm Hg. Hypoxemia was defined as oxygen saturation less than 90%. Apnea was defined as absence of spontaneous ventilation lasting 30 seconds.

And from the results section:

136 total cases.

Adverse events occurred in a total of 14 (10.3%; 95% CI 5.2%-15.4%) cases. Hypotension occurred in 5 (3.7%; 95% CI 0.5%-6.9%) patients, hypoxemia in 7 (5.1%; 95% CI 1.4%-8.8%), and apnea in 5 (3.7%; 95% CI 0.5%-6.9%).

Hypotension: All 5 cases responded to IV fluids, the lowest was 74/49. How many of you folks have patients who get a bit hypotensive while inducing them? I know you all have that syringe of phenylephrine in your scrub front pocket for a reason.

Hypoxemia: 7 total cases, lowest to 75%, 1 improved without intervention, 2 responded to simple oxygen, 3 responded to slight airway manipulation, and 1 had to be intubated (vomited, sats dropped to 75%). He was extubated 32 minutes later. No evidence of aspiration.

Apnea: 5 total cases. 1 needed no intervention. 2 more never desaturated and responded to mild physical stimulation. 1 required oxygen. And you already know about the 1 who required intubation.

Yes, we have complications. But we're not exactly talking about a 10% rate of death and dismemberment.

Are we better at giving anesthesia than anesthesiologists? No. Are we good enough for what we do? I think the literature would suggest the answer is probably.

 

[The White Coat Investor]

BTW Although I haven't had to perform a crich during residency - thankfully there are other ways to manage the airway before preceding to that, we all know how to use the equipment and have practiced numerous times on mannequins.

I'm glad to hear that. Ours here don't get any training.