Propofol for sedation in the intensive care unit: essentials for the clinician

The Effect of Propofol on the Success Rate of Transurethral Lithotripsy by Holmium Laser: A Randomized Clinical Trial

Introduction: Urinary stone disease is the third most common affliction of the urinary tract that has been associated with an increasing incidence. Over decades, great advances have been made in the minimally invasive treatment of urinary stones. Recently, transurethral lithotripsy (TUL) by holmium laser was introduced as a possible therapeutic option. This study evaluated the effect of propofol on the success rate of TUL by holmium laser. Methods: A double-blind randomized controlled trial was conducted on 180 patients to investigate the effect of propofol on the success and complication rate of TUL by holmium laser. The enrolled patients were divided into two groups: the first group received sodium thiopental (n=89) while the second group received propofol (n=91). The two groups were compared in terms of the fluctuations of systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), operation time, future stone-free rate (SFR), stone migration, post-operative fever, and ureteral complications such as perforation and mucosal damage. Other developed complications were also recorded. After data gathering, statistical analysis was performed with SPSS version 21. Results: the patients' data such as age, sex, stone diameter, stone laterality, duration of stone impaction, primary SBP, DBP and HR were not significantly different between the two groups (P>0.05). TUL and anesthesia duration, first-minute and fifth-minute SBP and DBP, and also changes of HR were significantly lower in the propofol group compared with the sodium thiopental group (P <0.001). Moreover, SFR of TUL was more evident in the propofol group. Ureteral mucosal damage was significantly less in the propofol group. Conclusion: Propofol was associated with a higher reduction in SBP and DBP, decreased duration of TUL, fewer fluctuations in HR, and an increased success rate of stone removal by TUL with holmium laser.

Safety and efficacy of non-anesthesiologist administration of propofol sedation during esophagogastroduodenoscopy in the intensive care unit

Background and study aims  Propofol sedation is an increasingly popular method of sedation for gastrointestinal endoscopic procedures. The safety and efficacy of the non-anesthesiologist administration of propofol (NAAP) sedation has been demonstrated in the ambulatory setting. However, NAAP sedation in intensive care unit (ICU) patients has not been reported. The purpose of this study is to determine safety and efficacy of NAAP sedation in an ICU population. Methods  We retrospectively reviewed esophagogastroduodenoscopies (EGD) performed with NAAP sedation in our intensive care units from June 2014 to September 2016. All EGDs were performed for evaluation of gastrointestinal bleeding. The primary end point of this study was to analyze the incidence of sedation-related adverse events (AEs). The secondary end points included successful completion of procedure and any endoscopic interventions performed. Results  Two of 161 procedures (1.2 %) had sedation-related AEs requiring procedure termination. One hundred forty-six of 161 procedures (90.7 %) were successfully completed. Incomplete procedures were due to excess heme, retained food or obstructive lesions (13/161, 8.1 %). Endoscopic intervention was performed successfully in 17/24 cases (70.8 %) that had endoscopically treated lesions identified. One hundred six of 161 patients (66 %) were American Society of Anesthesiologists (ASA) classification III or IV. Conclusion  Our retrospective analysis demonstrated that EGDs can be successfully completed in ICU patients using NAAP sedation. When procedures cannot be completed, it is rarely due to sedation-related AEs. NAAP sedation further allows adequate examination and successful treatment of high-risk lesions. NAAP sedation appears safe and effective for endoscopic procedures in the ICU setting.

Propofol-Based Palliative Sedation to Treat Antipsychotic-Resistant Agitated Delirium

Delirium is a common problem in terminally ill patients that is associated with significant distress and, hence, considered a palliative care emergency. The three subtypes of delirium are hyperactive, hypoactive, and mixed, depending on the level of psychomotor activity and arousal disturbance. When agitated delirium becomes refractory in the setting of imminent dying, the agitation may be so severe that palliative sedation (PS) is required. Palliative sedation involves the administration of sedative medications with the purpose of reducing level of consciousness for patients with refractory suffering in the setting of a terminal illness. Propofol is a sedative that has a short duration of action and a very rapid onset. These characteristics make it relatively easy to titrate. Reported doses range from 50 to 70 mg per hour. The authors present a case of antipsychotic-resistant agitated delirium treated with a propofol intravenous infusion.

Sedation in the Ambulatory Endoscopy Center: Optimizing Safety, Expectations and Throughput

In the United States, sedation and analgesia are the standard of practice when endoscopic procedures are performed in the ambulatory endoscopy center. Over the last 30 years, there has been a dramatic shift of endoscopic procedures from the hospital outpatient department to ambulatory endoscopy centers. This article will discuss sedation and analgesia in the ambulatory endoscopy center as it relates to optimizing safety, patient expectations, and efficiency.

Prolonged propofol infusion for mechanically ventilated children

We retrospectively analysed 30-day mortality and duration of intubation for 8016 children ventilated for three or more days, sedated with midazolam (n = 7716) or propofol (n = 300). We matched the propensity scores of 263 pairs of children. The propensity-matched 30-day mortality (95% CI) was similar: 17/263 (6.5%) with midazolam vs. 24/263 (9.1%) with propofol, p = 0.26. Weaning from mechanical ventilation of children sedated with midazolam was slower than weaning of children sedated with propofol, subhazard ratio (95% CI) 1.43 (1.18-1.73), p < 0.001.

A critical appraisal of sedation, analgesia and delirium in neurocritical care

Administering analgesics, sedatives and antipsychotics is challenging in the Neurological Intensive Care Unit (NICU). We reviewed this literature and our current practice to better inform the critical care practitioner and to identify gaps for future research. We electronically searched observational, intervention and outcome studies addressing sedation, analgesia and delirium in the NICU, and their bibliographies. Practice patterns were assessed in three critical care units with specialized neurological care in Montreal. Bedside pain assessment tools are psychometrically validated in the neuro-critically ill but sedation and delirium tools are not. Rigorous pain and sedation assessments appear feasible; delirium screening has not been tested. Publications addressing outcomes and responses to pharmacologic treatment lack consistency, rigor or both. In daily practice, pharmacologic management varies greatly. Clearly, little information exists on analgesia, sedation and delirium in the NICU. Systematic evaluation of pain improves outcome. No evidence-based therapeutic recommendations can be proffered.

Review of propofol and auxiliary medications used for sedation

The sedative-hypnotic propofol (2,6-diisopropylphenol) is being increasingly used for sedation during painful diagnostic and therapeutic procedures in adults and children. The purpose of this article is to present a general overview of the use of propofol for endoscopic sedation. Advantages and disadvantages of using propofol for sedation, as well as its pharmacokinetics, preparation for use, dosing for endoscopic sedation, auxiliary sedative and analgesic medication options, methods of administering, adverse effects with interventions, recovery, and patient-physician satisfaction are discussed. Finally, next steps necessary to optimize future use of propofol are suggested.

Medication-related complications in the trauma patient

Trauma patients are twice as likely to have adverse reactions to medication as nontrauma patients. The need for medication in trauma patients is high. Surgery is often necessary, and immunosuppression and hypercoagulability may be present. Adverse drug events can be caused in part by altered pharmacokinetics, drug interactions, and polypharmacy. Medications may also have serious long-term adverse effects, which must be considered. It is not the purpose of this review article to discuss all adverse effects of all medications. This article will discuss the more common adverse effects of medications for trauma patients in the acute care setting, in the following categories: pain control, sedation, antibiotics, seizure prophylaxis in head trauma, atrial fibrillation, deep vein thrombosis and pulmonary embolism prophylaxis, hemodynamic support, adrenal insufficiency, factor VIIa.

Propofol-related infusion syndrome in intensive care patients

The Institute of Medicine has identified adverse drug events as factors that significantly contribute to increased patient morbidity and mortality. As critically ill patients receive numerous drugs to treat a multitude of complicated health problems, they are at high risk for adverse drug events. Sedation is often a key requirement for the optimal management of critical illness, and propofol, a common sedative, has many desirable characteristics that make it the ideal agent in numerous circumstances. However, over the last decade, increasing numbers of reports have described a potentially fatal adverse effect called propofol-related infusion syndrome. Whether this adverse drug event is preventable is unclear, but recommendations have been proposed to minimize the potential for development of this syndrome. Research is under way to collect data on the use of propofol in intensive care units and on its prevalence.

Propofol use in pediatric patients with severe cancer pain at the end of life

This article describes the use and effectiveness of adjuvant propofol for pain control for pediatric oncology patients at the end of life. All patients experienced severe pain and agitation, not well controlled by continuous infusion opioids and benzodiazepines. Upon starting propofol, most patients had a temporary stabilization in the dose of opioids with subjective improvement in pain control, increased alertness, and improved ability to interact. Propofol infusions were continued until death in most patients. Two patients received propofol infusions at home. Subsequent increases in opioids in 6 patients and propofol in all patients were required for optimal pain control. Adverse effects included agitation in 5 patients and hallucinations in 2, which were controllable with benzodiazepines. One patient developed severe tetany, requiring propofol interruption; propofol was successfully restarted at a lower dose with an adjuvant benzodiazepine. The authors conclude that propofol is a useful and tolerable adjuvant agent for pain management in pediatric oncology patients at the end of life. It is a useful adjuvant if pain is unresponsive to continuous infusion opioids or if rapidly escalating doses of opioids are required.

Risk factors for cardiopulmonary events during propofol-mediated upper endoscopy and colonoscopy

BACKGROUND

Propofol-mediated sedation for endoscopy is popular because of its rapid onset and recovery profile.

AIM

To examine procedure-specific occurrence and risk factors for cardiopulmonary events during propofol-mediated upper endoscopy (EGD) and colonoscopy.

DESIGN

A cohort study using the Clinical Outcomes Research Initiative database was used to determine the frequency of cardiopulmonary events. Clinical Outcomes Research Initiative consisted of 69 practice sites comprising 593 US endoscopists. Multivariate logistic regression analysis used variables, such as age, ASA classification and propofol administration by monitored anaesthesia care or gastroenterologist-administered propofol to determine the risk of cardiopulmonary events.

RESULTS

The overall cardiopulmonary event rate for 5928 EGDs and 11 683 colonoscopies was 11.7/1000 cases. For colonoscopy, ascending ASA classification was associated with an increased risk. Monitored anaesthesia care was associated with a decreased adjusted relative risk (0.5, 95% CI: 0.36-0.72). ASA I and II patients receiving monitored anaesthesia care for EGD exhibited a significantly lower relative risk (ARR 0.29, 95% CI: 0.14-0.64). For subjects with ASA class III or greater, there was no difference in the risk between monitored anaesthesia care and gastroenterologist-administered propofol.

CONCLUSIONS

There are procedure-specific risk factors for cardiopulmonary events during propofol-mediated EGD and colonoscopy. These should be taken into account during future prospective comparative trials.

Propofol: a gastroenterologist's perspective

The use of propofol for GI endoscopy has left the realm of experimentation and is now a viable alternative to standard sedation and analgesia. In the hands of appropriately trained gastroenterologists and registered nurses, propofol has been shown to be superior to standard sedation and analgesia in terms of patient satisfaction and comfort and shorter recovery parameters. Comparative studies have found it to be as safe as the regimens that are used for standard sedation and analgesia. Its narrow therapeutic window demands that specially trained personnel who are not directly involved in the endoscopic procedure administer it. Cost-effectiveness data suggest that propofol is superior to conventional sedation and analgesia, even with the use of added personnel.The importance of pre-procedural assessment and appropriate monitoring cannot be overemphasized. The endoscopist must have a thorough knowledge of the pharmacology of the agents used for sedation and the training necessary to recognize and manage over sedation. Numerous regulatory groups are carefully scrutinizing the practice of sedation and analgesia. It seems that ventilatory monitoring will be required for at least a subset of patients. Although hypercapnia and apnea can be reliably measured, the most important questions to be answered are if such monitoring affects patient outcomes and which patients are at risk for apnea and alveolar hypoventilation.

Sedation and analgesia

In the United States sedation and analgesia is the standard of practice when performing upper and lower gastrointestinal endoscopy. Many of these endoscopic procedures are performed in ambulatory endoscopy centers, including ambulatory surgery centers. This article reviews new Joint Commission on Accreditation of Healthcare Organizations standards for sedation and analgesia, drugs used for sedation and analgesia (including side effects), patient assessment and monitoring (before, during, and postprocedure), and discharge of patients from the ambulatory endoscopy center.

The combined use of propofol and fentanyl for outpatient intravenous conscious sedation

BACKGROUND

Intravenous conscious sedation is currently being widely utilized for outpatient surgery including dermatologic surgery. Even though this type of anesthesia is typically administered by a trained, licensed anesthetist, it is important for dermatologists who either intend to or are currently utilizing this type of anesthesia to be familiar with some of the methods and agents that are commonly employed.

OBJECTIVE

Propofol and fentanyl are two anesthetic agents that are in prevalent use for skin and soft tissue surgery of brief or limited duration. With the goal of familiarizing dermatologic surgeons with this form of anesthesia, a study was conducted to evaluate the safety and effectiveness of the combination of propofol and fentanyl when used for conscious sedation in an outpatient dermatology center.

METHODS

Twenty patients, ages 25-65 years, who required conscious sedation were enrolled. Each patient received a standard dosage of fentanyl and propofol, as determined on a kilogram basis. Sedation time, total procedure time, recovery time, and total propofol dose, along with side effects, were determined.

RESULTS

The mean onset to sedation was 52.5 seconds, the mean procedure time was 40 minutes 37 seconds, and the mean interval to recovery was 3 minutes 43 seconds, with a mean total dose of propofol of 5.83 mg/kg. Minimal side effects occurred.

CONCLUSION

Propofol when used in conjunction with fentanyl appears to be a safe, quick, and effective method of providing conscious sedation.