Propofol Sedation in the Pediatric Emergency Department
Propofol Sedation in the Pediatric Emergency Department
abstract & commentary
Source: Havel CJ, et al. A clinical trial of propofol vs. midazolam for procedural sedation in a pediatric emergency department. Acad Emerg Med 1999;6:989-997.
Is it safe and effective to use propofol as a sedation agent in the pediatric ED? Havel and colleagues give us the first study of this agent in pediatric ED patients. The objectives of this prospective, blinded, randomized trial of morphine + propofol vs. morphine + midazolam were to compare the effectiveness (measured by a sedation score, time required to perform the procedure, and recall of the procedure), recovery time from sedation, and complication rate of the two sedation regimens. The subjects were children ages 2-18 years in the Children’s Hospital of Wisconsin ED with isolated extremity fractures that required a closed reduction.
There were 43 children enrolled in the propofol group (mean age, 9 ± 3.8) and 46 children enrolled in the midazolam group (mean age, 8.6 ± 4.2). Demographic information, anesthetic risk characteristics, and morphine doses were similar between the groups. Propofol compared favorably with midazolam in terms of depth of sedation achieved, time required to perform the reduction, and recall of the procedure. As expected, recovery time was considerably shorter in the propofol group (mean, 15 minutes vs 76 minutes in the midazolam group). Adverse effects were similar between the two groups, although Havel and associates acknowledge that "the small study population limits the power of this comparison."
Comment by Leonard Friedland, MD
Administering analgesics and benzodiazepines for procedural sedation is standard practice in the ED. Children presenting with painful and/or stressful conditions often require more than just a light level of sedation, and propofol seems to be ideal as it produces potent sedation within a minute, is short-acting, and has antiemetic properties. Propofol is extremely potent and works almost immediately; onset of action occurs up to four times faster than with midazolam. Dr. Steven Green, in his insightful commentary on this article, refers to the potential for propofol-induced rapid swings of consciousness and makes this analogy: "A car safely traveling 60 mph along the freeway may be impossible to keep within the dotted lines when driving substantially faster."1 The near-immediate onset of action with propofol will require continuous and vigilant attention to administration and syringe-pump titration, along with meticulous monitoring for adverse effects such as hypotension, hypoxemia, and loss of protective airway reflexes. A close look at the data demonstrate that one-third of the subjects in both the propofol and midazolam groups achieved a level of sedation measured as "no response to light glabellar tap or loud auditory stimulus" that lasted at least five minutes (mean duration of oversedation was 18 minutes in the propofol group and 34 minutes in the midazolam group). In my mind, this level of oversedation verges on general anesthesia! Carefully avoiding oversedation requires skill and experience. The longer onset of action of midazolam compared with propofol provides a relative safety zone, helping the ED physician avoid oversedation. As with the use of diazepam, midazolam, fentanyl, and ketamine (among other analgesia/sedation agents), the burden is now on the emergency medicine community to conduct studies and provide evidence that propofol can be safely used in our practice setting. This important article by Havel et al is the first step on this journey. In his commentary, Dr. Green sums it up best, for the time being: "Outside of IRB-approved research trials, emergency physicians would be wise to administer propofol only in those settings in which hospital-wide sedation policies specifically condone such use."
Reference
1. Green SM. Propofol for emergency department procedural sedation—not yet ready for prime time. Acad Emerg Med 1999;6:975-978.
Propofol:
a. is a widely used sedation agent for pediatric emergency department patients.
b. should only be used in the ED if your hospital-wide sedation policy specifically condones such use.
c. has a time of onset similar to that of midazolam.
d. is pro-emetic.
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