BMC Emergency Medicine Journal Club

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BMC Emergency MedicineJournal Club

• State of the Art Propofol Use in the ED
• March 2009

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Todays Agenda

• PROPOFOL State-of-the-Art
• Gina Lopez
• Scott Dresden

BMC EM Journal Club
BMC EM Journal Club
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Propofol

• Milk of amnesia
• C12H18O
• DiprivanTM
• DI-isoPRopyl IV Anesthetic

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Propofol

• Ingredients
• 1 propofol
• 10 soybean oil
• 1.2 purified egg phospholipid
• 2.25 glycerol
• Action sites
• GABA-A ? Glycine ? Endocannabinoid ?

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BMC Emergency MedicineJournal Club

• State of the Art Propofol Use in the ED
• Scott M. Dresden, MD

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CJEM 2007 9 421

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Background

• Propofol has recently gained increased attention
  for procedural sedation and analgesia in the ED
• Rapid onset, smooth, rapid recovery
• May lead to hypotension, apnea

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Objective

• Evaluate efficacy, safety, and patient
  satisfaction with the use of propofol for
  procedural sedation, analgesia in the ED

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Methods

• Prospective observational study
• Enrollment 113 consecutive patients receiving
  propofol for procedural sedation
• December 2003-November 2005

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Methods

• Vancouver General Hospital
• 700 bed adult tertiary referral centre
• Affiliated with University of British Columbia
• 62,000 ED visits/year

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Methods

• Protocol 3 people in room during sedation
• Attending EM physician
• Nurse
• Respiratory Therapist
• 0.25-0.5mg/kg propofol IV over 60 seconds
• 10-20mg/min IV until adequate sedation
• IV lidocaine and/or fentanyl permitted

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Patient Characteristics
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Key Results

• Efficacy
• 90 of procedures were successful
• Mean recovery time 7.6 mins (SD 3.4)
• Safety
• 1 patient with emesis and desaturation
• 9 patients with insignificant hypotension
• No major complications

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Key Results

• Patient Satisfaction

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Authors Conclusion

• A standardized protocol for procedural sedation
  and analgesia with propofol in the ED is safe and
  effective with high patient and physician
  satisfaction.

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Strengths of Article

• Standardized protocol
• Clearly defined rolls
• Same bolus and maintenance doses
• Consecutive patients selected
• Clearly written and well organized

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Limitations of Article

• Not comparative
• Small sample size
• Variability of fentanyl administration
• Did complicationsoccur with combo?
• Post procedurepain?

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Further Questions

• How many procedures were done using other
  sedatives?
• How many different attending physicians were
  involved in the study?
• Who recorded the data?
• Few complications due to low dose or
  standardized protocol?

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Final Comments

• Strong article, easy to read NO STATS
• Objectives clearly stated and met
• Conclusions supported by their data
• Results convincing that propofol can be safely
  used in the ED with proper adherence to
  protocol

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Yay Canada

• Written by Canadian Pharmacists

• In 2 languages

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Questions?
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BMC Emergency MedicineJournal Club

• State of the Art Propofol Use in the ED
• Gina Lopez, MD, MPH

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Ann Emerg Med. 2008 52(4) 392-398
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Why should I care what they say?

• Dr. Steven Green
• 47 articles from 2002 present
• 24 related to conscious sedation
• Dr. Baruch Krauss
• 34 articles from 2002 present
• 26 related to conscious sedation
• Focus on safety considerations
• Pioneers in characterizing ketamine use for
  conscious sedation in pediatrics

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ASA Definitions of General Anesthesia and Levels
of Sedation/Analgesia
Moderate Sedation
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Background

• In the ED, we utilize conscious sedation for a
  wide range of procedures
• Propofol has properties that make it ideal for
  use in the ED
• 28 published series on ED propofol in 3811 pts
  showing it to be safe effective
• Historically, there have been many barriers to
  propofol use in the ED

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Objective

• Identify and discuss the most common barriers of
  propofol use in the ED
• No Null Hypothesis

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Methods

• Type of paper Commentary
• Written by two emergency medicine physicians
• Systematic review of barriers to ED propofol use

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Outline

• Terminology nonanesthesiolgist
• Who decides who can use propofol?
• Criticisms and Rebuttals
• Financial concerns

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Nonanesthesiologist

• In 2002, the ASA noted practice guidelines for
  sedation and analgesia by nonanesthesiolgists
• - Term never defined
• - There is a spectrum of skills
• ARGUMENT Propofol use should be based on skills
  not this arbitrary dichotomy

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Who Decides Who Uses Propofol?

• Specialty guidelines may be cited in litigation
  but no authority on their own
• Joint Commission set basic standards
• Hospital Leadership true authority in setting
  sedation guidelines
• May delegate responsibility to anesthesia chiefs
• Often an interdisciplinary sedation committee

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Criticisms Rebuttals
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Semantics

• Product Labeling
• ASA/AANA Joint Statement
• ASA Deep Sedation Statement
• And
• Propofol oversedation is general anesthesia
• Deep sedation ? general anesthesia ED physician
  qualified to rescue patient if necessary

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Safety Concerns

• Respiratory Depression
• Aspiration
• Not supported by evidence
• No propofol-specific antagonist
• Not necessary since such short half-life
• Technically difficult
• Oversedation
• ED physicians are qualified to do RSI, manage
  airways and monitor levels of sedation

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Financial Concerns

• Poachers and Dabblers
• Do anesthesiologists really want to come down to
  the ED for our conscious sedation?
• The ED isnt a great source of revenue

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Authors Conclusion

• Propofol is safe for conscious sedation when
  supervised by a residency trained emergency
  physician
• Emergency physicians should become represented on
  the hospital sedation committee establishing safe
  protocols for the use of propofol for conscious
  sedation
• "Deep sedation using propofol is rapidly evolving
  into an essential emergency medicine skill, and
  emergency physicians must overcome barriers to ED
  propofol use for the benefit of our patients"

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Strengths of Article

• Written by two of the leaders in conscious
  sedation in emergency medicine
• Systematic approach to the most common barriers
• Cites the evidence to support the safe use of
  propofol in the ED

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Limitations of Article

• Its just a commentary
• Biased
• Written by two emergency medicine physicians
• 8 of 31 citations include one of the authors

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Further Questions

• What exactly does the latest ASA statement on
  propofol use outside the operating room say?
• What is the safety data in the anesthesia
  literature on propofol use for conscious sedation?

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Final Comments

• Nice basic overview of the issues from the ED
  perspective
• "Deep sedation using propofol is rapidly
  evolving into an essential emergency medicine
  skill, and emergency physicians must overcome
  barriers to ED propofol use for the benefit of
  our patients
• This conclusion is a stretch because doesnt
  really present evidence to support why using
  propofol is essential or how it will benefit
  our patients

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Upcoming Journal Clubs

• April 14 Infectious Disorders
• Megan Salinas (EM2)
• Jason Delong (EM1)
• May 12 Musculoskeletal Disorders Levenberg and
  Stanton
• June 9 Nervous System Disorders Sullivan and
  Horesji

BMC EM Journal Club
BMC EM Journal Club