PropofolGiven all the recent brouhaha around propofol and Michael Jackson, I thought I would review the 2007 Annals of EM Clinical Practice Advisory paper on the use of propofol in the Emergency Department for procedural sedation. This is one of the 2009 Lifelong Learning Self-Assessment (LLSA) articles. Each year EM-board certified physicians are tested on 20 pre-selected LLSA articles to maintain eligibility for re-certification.

Also, I’m in the process of writing and submitting my handouts for the upcoming 2009 American College of Emergency Physicians scientific assembly, where I’ll be giving some lectures. One lecture focuses on reviewing 4 of the 20 articles. One of these is the propofol review article.

Propofol is an IV sedative-hypnotic agent, which is arguably the most popular procedural sedation agent in the Emergency Department. Patients often wake up thinking that the procedure hasn’t started yet. To their surprise, their dislocations are relocated, fractures are reduced, abscesses are drained, or cardioversion is done. It is NOT, however, an analgesic and so opiates should be given prior to propofol for pain control.

Indications for propofol use:

  • Any short, painful procedures in the ED requiring deep sedation

Contraindications:

  • Absolute: allergy to propofol, eggs, or soy products
  • Relative: Age >55 years, debilitation, or significant co-morbidities

Pharmacology of propofol:

  • Sedation is dose-dependent
  • Average time to onset of sedation = 30 seconds
  • Average time to resolution of sedation = 6 minutes
  • Standard ED dosing = 1 mg/kg IV, followed by 0.5 mg/kg every 3 minutes titrated to sedation

Associated complications:

  • Lack of adequate sedation
  • Oversedation
  • Hypoxemia
  • Respiratory depression – Bag valve mask rescue ventilation in 3.0-9.4%
  • Respiratory arrest
  • Airway obstruction and apnea
  • Nausea/vomiting
  • Pain with injection – May consider priming IV line with 0.5 mg/kg lidocaine
  • Transient hypotension –
    • Especially in patients > 55 years old, consider starting at lower propofol dose.
    • If possible, IV hydrate patient to minimize systolic blood pressure drop. Pronounced hypotension occurs more often in those who are intravascularly depleted.

BOTTOM LINE:

Propofol is great for procedural sedation in the ED with appropriate monitoring and airway adjuncts. Bad when used at home.

Reference:
Miner JR, Burton JH. Clinical practice advisory: Emergency department procedural sedation with propofol. Ann Emerg Med. 2007 Aug;50(2):182-7, 187.e1.

Michelle Lin, MD
ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
Michelle Lin, MD

@M_Lin

Professor of Emerg Med at UCSF-Zuckerberg San Francisco General. Founder of ALiEM @aliemteam #PostitPearls https://t.co/7v7cgJqNEn
Michelle Lin, MD