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Is propofol an optimal agent for procedural sedation and rapid sequence intubation in the emergency department?

Published online by Cambridge University Press:  21 May 2015

Kerry Wilbur  and
Peter J. Zed
Kerry Wilbur*
Affiliation:
Internal Medicine, Vancouver Hospital and Health Sciences Centre, Vancouver, BC Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC
Peter J. Zed
Affiliation:
Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC Emergency Medicine, Vancouver Hospital and Health Sciences Centre
*
CSU Pharmaceutical Sciences, Vancouver Hospital and Health Sciences Centre, 855 West 12th Ave., Vancouver BC V5Z 1M9; 604 875–4077, fax 604 875–5267, [email protected]

Abstract

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Objective:

We conducted a qualitative systematic review to evaluate the efficacy and safety of propofol for direct current cardioversion (DCC), rapid sequence intubation (RSI) and procedural sedation in adult emergency department (ED) patients.

Data source:

MEDLINE (1966 to September 2000), PubMed (to September 2000), EMBASE (1988 to September 2000), Database of Systematic Reviews (to September 2000), Best Evidence (1991 to September 2000) and Current Contents (1996 to September 2000) databases.

Study selection:

English-language, randomized, comparative evaluations of propofol for procedures routinely conducted in adults (>18 years) were included. Direct current cardioversion, RSI and procedural sedation were considered.

Data extraction:

Efficacy and safety endpoints were evaluated for all trials. For DCC and procedural sedation trials, efficacy measures included induction and recovery times, as well as the association for successful procedure. For the RSI trials, optimal intubating conditions were evaluated as the primary efficacy endpoint. Safety measures included hemodynamic changes, apnea rates and adverse effects.

Data synthesis:

In the setting of DCC, efficacy and safety outcomes were similar for propofol, thiopental, etomidate and methohexital. All of these agents provided markedly shorter induction and recovery times than midazolam. Patients who were pre-medicated with fentanyl exhibited prolonged recovery times and greater decreases in blood pressure. When used for RSI, propofol administration was associated with satisfactory intubating conditions that were comparable to those seen with thiopental and etomidate. Blood pressure reductions were seen in both DCC and RSI studies. Apneic episodes (>30 seconds) occurred in 23% of propofol recipients, 28% of thiopental recipients and 7% of etomidate and midazolam recipients. Apart from the DCC studies described, no procedural sedation studies met our predefined review eligibility criteria.

Conclusion:

The body of literature evaluating propofol for DCC and RSI in the ED is limited. There is evidence to support the use of propofol for DCC and RSI, but this evidence comes from stable patients in non-ED settings. Further ED-based randomized comparative trials should be conducted before propofol is adopted for widespread use in the ED.

Résumé

RÉSUMÉObjectif:

Nous avons mené une revue qualitative méthodique afin d’évaluer l’efficacité et l’innocuité du propofol pour la cardioversion, l’intubation à séquence rapide (ISR) et la sédation procédurale chez les patients adultes reçus à l’urgence.

Source des données:

Les banques de données de MEDLINE (1966 à septembre 2000), PubMed (jusqu’à septembre 2000), EMBASE (1988 à septembre 2000), Database of Systematic Reviews (jusqu’à septembre 2000), Best Evidence (1991–septembre 2000) et Current Contents (1996–septembre 2000).

Choix d’étude:

Des évaluations en langue anglaise randomisées, comparatives du propofol pour les interventions routinières chez des adultes (>18 ans) furent incluses. La cardioversion, l’ISR et la sédation procédurale furent étudiées.

Collecte des données:

Les paramètres d’efficacité et d’innocuité furent évalués pour tous les essais. Pour les essais de cardioversion et de sédation procédurale, les paramètres d’efficacité comprenaient les délais d’induction et de récupération, ainsi que l’association pour une intervention réussie. Pour les essais de l’IRS, les conditions optimales d’intubation furent évaluées comme le principal paramètre d’efficacité. Les paramètres d’innocuité comprenaient les changements hémodynamiques, les taux d’apnée et les effets indésirables.

Synthèse des données:

Dans le cadre de la cardioversion, les résultats de l’efficacité et de l’innocuité furent similaires pour le propofol, le thiopental, l’étomidate et le méthohexital. Tous ces agents procurèrent des temps d’induction et de récupération significativement plus courts que le midazolam. Les patients ayant reçu une pré-médication au fentanyl présentaient des temps de récupération prolongés et un abaissement plus marqué de la tension artérielle. Administré lors de l’ISR, le profolol était associé à des conditions d’intubation satisfaisantes qui étaient comparables aux conditions observées avec le thiopental et l’étomidate. Des diminutions de la tension artérielle furent observées tant dans le cadre des études de la cardioversion que de l’ISR. Des épisodes d’apnée (>30 secondes) se produisirent chez 23% des patients traités au propofol, 28 % des patients traitées au thiopental, et 7 % des patients traités à l’étomidate et au midazolam. Mis à part les études de cardioversion décrites, aucune étude de sédation procédurale ne répondait à nos critères d’admission prédéfinis.

Conclusion:

La littérature évaluant le rendement du propofol pour la cardioversion et l’ISR à l’urgence est limitée. Des preuves existent appuyant le recours au propofol pour la cardioversion et l’ISR, mais celles-ci ont été observées chez de patients stables dans des conditions non urgentes. On devrait procéder à d’autres essais randomisés à l’urgence avant d’adopter le propofol pour usage répandu au département d’urgence.

Keywords

propofolrapid sequence intubationconscious sedationprocedural sedationcardioversionthiopentaletomidatemidazolam
Type
State of the Art • Innovations
Information
Canadian Journal of Emergency Medicine , Volume 3 , Issue 4 , October 2001 , pp. 302 - 310
Copyright
Copyright © Canadian Association of Emergency Physicians 2001

References

1.Innes, G, Murphy, M, Nijssen-Jorden, C, Ducharme, J, Drummond, A.Procedural sedation and analgesia in the emergency department. Canadian consensus guidelines. J Emerg Med 1999;17:145–56.Google Scholar
2.American College of Emergency Physicians. The use of pediatric sedation and analgesia [policy statement]. Ann Emerg Med 1993;22:626–7.Google Scholar
3.Gerardi, MJ, Sacchetti, AD, Cantor, RM, Santamaria, JP, Gausche, M, Lucid, W, et al. Rapid-sequence intubation of the pediatric patient. Ann Emerg Med 1996;28:55–74.Google Scholar
4.Schneider, MS, Coates, WC.Use of ultrashort-acting hypnotic agents in emergency departments. West J Med 1996;164:64–5.Google Scholar
5.Grafstein, E, Innes, G, Roland, K.Do injection drug users have different medication requirements in procedural sedation? [abstract]. CJEM 2000;2(3):180.Google Scholar
6.Innes, G, Grafstein, E, Christenson, JM, Roland, K.Ketamine vs. fentanyl/midazolam for procedural sedation in intravenous drug users [abstract]. CJEM 2000;2(3):185.Google Scholar
7.Wright, SW, Chudnofsky, CR, Dronen, SC, Wright, MB, Borrow, SW.Midazolam use in the ED. Am J Emerg Med 1990;8:97–100.Google Scholar
8.Ramoska, EA, Linkenheimer, R, Glascow, C.Midazolam use in the ED. J Emerg Med 1991;9:247–51.Google Scholar
9.Chudnofsky, CR, Wright, SW, Dronen, SC, Borron, SW, Wright, MB.The safety of fentanyl use in the ED. Ann Emerg Med 1989;18:635–9.Google Scholar
10.Epstein, FB.Ketamine dissociative sedation in pediatric emergency medical practice. Am J Emerg Med 1993;11:180–2.Google Scholar
11.Chudnofsky, CR, Weber, JE, Stoyanoff, PJ, Colone, PD, Wilkerson, MD, Hallinen, DL, et al. A combination of midazolam and ketamine for procedural sedation and analgesia in adult emergency department patients. Acad Emerg Med 2000;7:228–35.Google Scholar
12.Sivilotti, MLA, Ducharme, J.Randomized, double-blind study on sedatives and hemodynamics during rapid-sequence intubation in the emergency department: The SHRED Study. Ann Emerg Med 1998;31:313–24.Google Scholar
13.Sokolove, PE, Price, DD, Okada, P.The safety of etomidate for emergency rapid sequence intubation of pediatric patients. Pediatr Emerg Care 2000;16:18–21.Google Scholar
14.Smith, DC, Bergen, JM, Smithline, H, Kirschner, R.A trial of etomidate for rapid sequence intubation in the emergency department. J Emerg Med 2000;18:13–6.Google Scholar
15.Bergen, JM, Smith, DC.A review of etomidate for rapid sequence intubation in the emergency department. J Emerg Med 1997;15:221–30.Google Scholar
16.Mirenda, J, Broyles, G.Propofol as used for sedation in the ICU. Chest 1995;108:539–48.Google Scholar
17.Bryson, HM, Fulton, BR, Faulds, D.Propofol: an update of its use in anaesthesia and conscious sedation. Drugs 1995;50:513–59.Google Scholar
18.Valtonen, M, Kanto, J, Klossner, J.Anaesthesia for cardioversion: a comparison of propofol and thiopentone. Can J Anaesth 1988; 35:479–83.Google Scholar
19.Gupta, A, Lennmarken, C, Vegfors, M, Tayden, H.Anesthesia for cardioversion. A comparison between propofol, thiopenton, and midazolam. Anaesthesia 1990;45:872–5.Google Scholar
20.Canessa, R, Guillermo, L, Urzua, J, Dagnino, J, Concha, M.Anesthesia for elective cardioversion: a comparison of four anesthetic agents. J Cardiothor Vasc Anesth 1991;5:566–8.Google Scholar
21.Sternlo, JE, Hagerdal, M.Anaesthesia for cardioversion – clinical experience with propofol and thiopentone. Acta Anaesthesiol Scan 1991;35:609–15.Google Scholar
22.Hullander, RM, Leivers, D, Wingler, K.A comparison of propofol and etomidate for cardioversion. Anesth Analg 1993;77:690–4.Google Scholar
23.Gale, DW, Usaf, M, Grissom, TE, Mirenda, JV.Titration of intravenous anesthetics for cardioversion: a comparison of propofol, methohexital, and midazolam. Crit Care Med 1993;21:1509–13.Google Scholar
24.Dobson, AP, McCluskey, A, Meakin, G, Baker, RD.Effective time to satisfactory intubation conditions after administration of rocuronium in adults. Comparison of propofol and thiopentone for rapid sequence induction of anaesthesia. Anaesthesia 1999; 54:172–97.Google Scholar
25.Skinner, HJ, Biswas, A, Mahajan, RP.Evaluation of intubating conditions with rocuronium and either propofol or etomidate for rapid sequence induction. Anaesthesia 1998;53:702–10.Google Scholar
26.Earnes, WO, Rooke, A, Sai-Chuen, R, Bishop, MJ.Comparison of the effects of etomidate, propofol, and thiopental on respiratory resistance after tracheal intubation. Anesthesiology 1995;83: 1307–11.Google Scholar
27.Beck, GN, Masterson, GR, Richards, J, Bunting, P.Comparison of intubation following propofol and alfentanil with intubation following thiopentone and suxamethonium. Anaesthesia 1993; 48:876–80.Google Scholar
28.Sparr, HJ, Giesinger, S, Ulmer, M, Hollenstein-Zacke, M, Luger, TJ.Influence of induction technique on intubating conditions after rocuronium in adults: comparison with rapid-sequence induction using thiopentone and suxamethonium. Br J Anaesth 1996;77:339–42.Google Scholar
29.Lindgren, L, Yli-Hankala, A, Randell, T, Kirvela, M, Scheinin, M, Neuvonen, PJ.Haemodynamic and catecholamine responses to induction of anaesthesia and tracheal intubation: comparison between propofol and thiopentone. Br J Anaesth 1993;70:306–10.Google Scholar
30.Groener, R, Moyes, DG.Rapid tracheal intubation with propofol, alfentanil and a standard dose of vecuronium. Br J Anaesth 1997;791:384–5.Google Scholar
31.Hug, CC Jr, McLeskey, CH, Nahrwold, ML, Roizen, MF, Stanley, TH, Thisted, RA, et al. Hemodynamic effects of propofol: data from over 25,000 patients. Anesth Analg 1993;77(Suppl):S21–9.Google Scholar
32.El-Beheiry, H, Kim, J, Milne, B, Deegobin, R.Prophylaxis against the systemic hypotension induced by propofol during rapid-sequence intubation. Can J Anaesth 1995;42:875–8.Google Scholar
33.Peacock, JE, Lewis, RP, Reilly, CS, Nimmo, WS.Effect of different rates of infusion of propofol for induction of anesthesia in elderly patients. Br J Anaesth 1990;65:346–52.Google Scholar
34.Rolly, G, Versichelen, L, Huyghe, L, Mungroop, H.Effect of speed of injection on induction of anaesthesia using propofol. Br J Anaesth 1985;57:743–6.Google Scholar
35.Gillies, GWA, Lees, NW.The effects of speed of injection on induction with propofol. Anaesthesia 1989;441:386–8.Google Scholar
36.Dundee, JW, Robinson, FP, McCollum, JSC, Patterson, CC.Sensitivity to propofol in the elderly. Anaesthesia 1986;41:482–5.Google Scholar
37.McCollum, JS, Dundee, JW.Comparison of induction characteristics of four intravenous anesthetic agents. Anaesthesia 1986;41:995–1000.Google Scholar
38.Blouin, RT, Conrad, PF, Gross, JB.Time course of ventilatory depression following induction doses of propofol and thiopental. Anesthesiology 1991;75:940–4.Google Scholar
39.American Society of Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 1996;84:459–71.Google Scholar
40.Picard, P, Tramer, MR.Prevention of pain on injection with propofol: a quantitative systematic revew. Anesth Analg 2000; 90:963–9.Google Scholar
41.Johnson, RA, Harper, NJ, Chadwick, S, Vohra, A.Pain on injection of propofol. Methods of alleviation. Anaesthesia 1990 45: 439–42.Google Scholar
42.Totten, VY, Zambito, RF.Propofol bolus facilitates reduction of luxed temporomandibular joints. J Emerg Med 1998;16:467–70.Google Scholar
43.Swanson, ER, Seaberg, DC, Stypula, RW, Troianos, CA.Propofol for conscious sedation: a case series. Acad Emerg Med 1995; 2:661–3.Google Scholar
44.Swanson, ER, Seaberg, DC, Mathias, S.The use of propofol for sedation in the emergency department. Acad Emerg Med 1996; 3:234–8.Google Scholar
45.Innes, G.Emergency department sedation guidelines: a tale of two specialties [editorial]. CJEM 1999;1(2):88.Google Scholar
46.Green, SM.Propofol for emergency department procedural sedation – not yet ready for prime time. Acad Emerg Med 1999; 6:975–8.Google Scholar
47.Bailey, PL, Pace, NL, Ashburn, MA, Moll, JW, East, KA, Stanley, TH.Frequent hypoxemia and apnea after sedation with midazolam and fentanyl. Anesthesiology 1990;73:826–30.Google Scholar