Use of propofol sedation in the paediatric emergency department

Your colleagues in the emergency department are very keen to start using propofol for conscious sedation of children who require reduction of fractures or other painful procedures in the emergency department. They have had good experience using this drug with adult patients and are comfortable using it. When this is discussed at the pharmacy and therapeutics committee, one of the paediatric intensive care physicians raises the issue of the safety of propofol for children. The chair of the committee would like your input. The management of acute pain and anxiety in children undergoing diagnostic or therapeutic procedures is an on-going challenge, especially in urgent care settings. Analgesia and sedation are increasingly being used to reduce the pain and anxiety associated with urgent and acute care of children (1). This raises new issues for clinicians regarding the selection of the appropriate agent. Propofol (2,6-diisopropylphenol) is a nonopioid, nonbarbiturate, short-acting anesthetic agent that must be administered intravenously (2). Although originally confined to operating rooms and intensive care units, propofol use is becoming more popular in ambulatory care areas to facilitate short procedures, because it has both the advantage of rapid induction and recovery time. In the operating room, propofol has been used extensively for paediatric anesthesia with a good track record in terms of efficacy and safety (3). The common adverse effects associated with propofol therapy include cardiopulmonary depression, upper airway obstruction, hypoventilation and apnea leading to hypoxemia (in up to 10% of patients) (4–6). A recent major issue with respect to the use of propofol has been the use of this drug for sedation of paediatric intensive care patients. This has been reinforced by a warning from Health Canada that propofol use is contraindicated for patients under 18 years of age in intensive care units (7). A potentially fatal complication known as ‘propofol infusion syndrome’ has been described in critically ill children given long term propofol infusion, the syndrome being characterized by the development of severe metabolic acidosis and rhabdomyolysis associated with hepatomegaly, lipemia, myocardial failure and hyperkalemia (7,8). This syndrome appears to occur primarily with long term propofol use in critically ill children who often have serious underlying pathology or are being treated with multiple drugs that may alter propofol metabolism, rather than with the use of propofol for brief procedural sedation. Thus, the issues with which Health Canada is concerned regarding propofol use in paediatric intensive care units are probably not germane to the use of propofol in the emergency department. However, there are other issues with respect to the use of propofol for procedural sedation. As propofol does not have analgesic properties, concurrent opioid therapy using agents such as fentanyl or morphine is common, but this can be associated with an increased risk of respiration depression and hypotension. Propofol can interact in a synergistic manner with opioids as well as decrease elimination and distribution clearance of opioids related to the metabolic alteration of opioid clearance. Hence, plasma concentration of opioids (and opioid effects) can increase in the face of concurrent therapy with propofol. As well, opioids may decrease propofol elimination clearance. It should be remembered by all clinicians using propofol that this agent was developed initially for use in the operating room, and thus, patients undergoing sedation for diagnostic or therapeutic procedures with propofol (or indeed, any conscious sedation) should be carefully monitored (9,10). Before proceeding, informed consent must be obtained and the clinician must ensure that the child has fasted for an appropriate period of time. During the procedural sedation, basic monitoring should include continuous assessment of peripheral blood oxygen saturation, respiratory rate and heart rate monitoring, with regular intermittent blood pressure measurement and assessment of depth of sedation using an appropriate technique or scale. Expert personnel and facilities for securing and maintaining a patent airway and providing oxygen and artificial ventilation for children of the age in question must be immediately available. Personnel who are experts in cardiopulmonary resuscitation in children must always be immediately available. All children receiving propofol must have a secure intravenous access in place. Provisions must be made for monitoring for ongoing titration of the propofol dose by personnel who are experts in such assessments. How will we answer the question raised by our colleagues in the emergency department? Studies to date have demonstrated that propofol has comparable amnestic effects as ketamine and midazolam for procedural sedation (4–6). Advantages of propofol with respect to midazolam are more rapid onset of sedation, shorter recovery time, smoother emergence and antiemetic properties. Also, there is a relative lack of effects on intracranial pressure with propofol compared with ketamine. However, disadvantages of propofol include relatively high incidences of hypotension and apnea compared with ketamine and midazolam. Thus, propofol may be a useful agent in the paediatric emergency department, especially when it is important not to increase intracranial pressure, but the decision to use propofol means that: Facilities for continuous monitoring of heart rate and oxygen saturation must be available; Personnel in attendance must be expert in securing and maintaining an airway in children, including by use of endotracheal intubation; There must be adequate facilities to recover the patient after the procedure, including monitoring as described above; and The drug should be given slowly with close attention to oxygenation, level of consciousness and blood pressure.

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