Regarding the article on the use of propofol in the March 2006 issue of the Patient Safety Advisory (Vol. 3, No. 1), I wanted to comment about the use of this agent for procedural sedation in the emergency department. Use of this agent in the emergency department was not discussed in the article.
In the non-intubated emergency department patient, propofol is typically used for brief, painful procedures. The prototype example of such a procedure is reduction of a shoulder dislocation. In a properly sedated patient, the actual procedure often takes less than one minute. Trained emergency physicians are skilled at airway and ventilation monitoring and can intervene if problems occur. Although propofol use has been controversial in some settings, more and more data are becoming available about its use in the emergency department for brief sedation. In fact, studies are showing that propofol sedation is more safe than traditional agents.1,2 Furthermore, while it is true that there is no reversal agent for propofol, the ultra-short half life of the drug minimizes the need for a reversal agent. By the time a reversal agent could be administered after a standard 1 mg/kg bolus of propofol had been given, the propofol effect would be rapidly disappearing or perhaps even gone.
We have recently begun using propofol for brief procedures in our emergency department. Furthermore, we are participating in a multi-hospital procedural sedation registry. Our experience and the experience documented in the registry are consistent with decreased complication rates when propofol is used compared to when traditional agents are used. Problems like transient apnea and hypoxemia can occur with any agent, but we are finding that the rate of such events is about 5 times less in cases where propofol was used compared to cases where propofol was not used (unpublished data).
Articles in publications such as this can be very influential at individual hospitals, and thus they should be evidence-based and cover the appropriate use of propofol in all settings, including the emergency department. I hope that when the authors update this article, they include an evidence-based section applicable to the emergency department.
Gary Senula, MD, MBA
Medical Director, Emergency Services
Susquehanna Health System
Notes
Burton, J, et al. Propofol for Emergency Department Procedural Sedation and Analgesia: A Tale of Three Centers. Acad. Emerg. Med. 2006;13:24-30.
- Parlak, M, et al. Age Effect on Efficacy and Side Effects of Two Sedation and Analgesia Protocols on Patients Going through Cardioversion: A Randomized Clinical Trial. Acad. Emerg. Med. 2006;13:493-9.
Editor’s Note:
As Dr. Senula points out, published and anecdotal reports do describe the advantages that propofol offers over other drugs used for procedural sedation. However, reports submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) and elsewhere illustrate that when propofol is involved in a medication error the consequences can be catastrophic. This does not mean that the drug cannot be used safely and effectively. It only indicates that precautions should be taken to safeguard its use, no matter the length or location of the procedure.
The error reports we have analyzed describe system breakdowns that have contributed to medication errors involving propofol, negating any benefits the drug may have. Factors such as lack of complete drug information for staff, inadequate staff training/mentoring before propofol is used, unavailability of qualified staff not involved in the procedure to continuously monitor the patient, and lapses in monitoring when the patient is transportedfrom the unit or ED to radiology create an environment in which medication errors such as the following can occur:
Propofol used in ED during rapid sequence intubation found to be running at a rate higher than expected. Patient was in cardiac arrest. Intubation was difficult. Nurse was more focused on resuscitation than medication administration.
Patient ordered propofol at 20 mcg/kg/min. Upon arrival on unit from ED, rate found to be set at 20 mL/min. Last documentation from ED indicated rate at 20 mL/min.
Our intent was not to discourage the use of propofol in appropriate situations. However, we felt it necessary, based on the number of reports submitted to PA-PSRS and other reporting programs, to describe how problems can occur during propofol administration and to provide strategies to prevent future problems. We hope that facilities will evaluate who, where, and how propofol is used and implement a comprehensive plan to safely administer and monitor propofol.