Review article: Safety profile of propofol for paediatric procedural sedation in the emergency department

Comparison of propofol-based sedation and midazolam sedation in pediatric bidirectional endoscopy conducted by pediatric gastroenterologists

Objectives

The effectiveness and safety of propofol-based sedation and midazolam sedation in pediatric bidirectional endoscopy were compared.

Methods

We retrospectively analyzed the cases of pediatric patients (≤15 years old) who had undergone bidirectional endoscopy, esophagogastroduodenoscopy, and colonoscopy by pediatric gastroenterologists. Demographic data, indications, sedatives/dosages, clinical outcomes, endoscopic findings, adverse events, and total patient time requirements (total time in which patients stay in our hospital) were compared in the two sedation groups.

Results

Ninety-one children (51 boys, 40 girls, mean age 13 years, range 9-15) treated at our hospital were enrolled. Propofol alone or in combination with midazolam and/or pentazocine was administered to 51 patients (propofol-based sedation group). Midazolam alone or in combination with pentazocine was administered to the other 40 patients (midazolam sedation group). In the propofol group, the following mean doses were used: propofol, 96 mg (range 40-145 mg); midazolam, 4.9 mg (range 3-5 mg); and pentazocine, 7.5 mg. In the midazolam group, the mean doses of midazolam and pentazocine were 6.2 mg (range 4-10 mg) and 15 mg, respectively. All procedures were successfully completed by pediatric gastroenterologists. The total procedure times and endoscopic findings were similar in the two groups, but the median patient time requirement in the propofol group was significantly shorter versus the midazolam group (7.3 h vs. 8.4 h, p < 0.001). No adverse events occurred in either group.

Conclusions

Propofol-based sedation in pediatric bidirectional endoscopy was safely and effectively performed by pediatric gastroenterologists, and its patient time requirement was shorter than that for midazolam sedation.

Scoping review finds insufficient evidence on potential risks of procedural sedation with dexmedetomidine in children

AIM

Dexmedetomidine is commonly used in hospitals for sedation during procedurals. It has been considered safe even though studies have shown that it may cause bradycardia and hypotension. The aim of this study was to map the current evidence regarding potential risks of sedation of children with dexmedetomidine.

METHODS

Two database searches were conducted to gather all articles published through 30 January 2024 that matched the inclusion criteria. PubMed and Embase were chosen for the initial search. Search terms were chosen to create a broad systematic search that would include articles reporting adverse events during procedural sedation on children. From the included articles, data on type of sedation, administration, patient characteristics, endpoints and number of adverse events were collected.

RESULTS

After the initial search, 357 individual papers were screened and 41 papers were included. The most common adverse event reported was bradycardia. In almost 40% of the articles that measured oxygen saturation, one or more incidents of desaturation occurred. 27% reported that interventions to prevent further harm were preformed, most of the interventions were to improve oxygenation.

CONCLUSION

There is a need for further investigation regarding adverse events, especially respiratory adverse events during sedation with dexmedetomidine.

Delayed Adverse Events after Procedural Sedation in Pediatric Patients with Hematologic Malignancies

Background and objectives: Procedural sedation for bone marrow examination (BME) and intrathecal chemotherapy (ITC) is necessary for pediatric patients with hematological malignancies. There has been no report on adverse events after discharge from the recovery room. This retrospective study evaluated the types and incidences of delayed adverse events among pediatric patients scheduled for BME or ITC under deep sedation in a single center for 3 years. Materials and Methods: The patients were divided into two groups: inpatients (group I) and outpatients (group O). All patients were managed during the procedures and the recovery period. In total, 10 adverse events were assessed; these occurred 2 h (T1, acute), 12 h (T2, early), and 24 h (T3, delayed) after the procedure. The duration of each adverse event was also recorded and was classified as 2 h (D1), 12 h (D2), or 24 h (D3). The data of 263 patients (147 inpatients and 116 outpatients) who met the inclusion criteria were analyzed. Results: The overall incidence of adverse events was statistically significant difference: 48.3% in group I and 33.6% in group O (p = 0.011). The rates of adverse events at T1 and T2 were significantly different between groups I and O (42.8% vs. 11.2% and 7.5% vs. 20.7%, respectively) (p < 0.001). The adverse events were mostly of D1 or D2 duration in both groups. Patients with a higher proportion of ketamine in a propofol−ketamine mixture had a significantly higher proportion of adverse events at T1 (34.6%), as compared with those with a mixture with a lower proportion of ketamine (21.1%) or propofol alone (17.9%) (p = 0.012). Conclusions: The most common adverse events were dizziness or headache; typically, they did not last longer than 12 h. The propofol-ketamine combination with a higher proportion of ketamine seems to produce more adverse events within 2 h after the procedure. Nevertheless, all sedative types appear safe to use without additional management.

The Impact of a Dedicated Sedation Team on the Incidence of Complications in Pediatric Procedural Analgosedation

The number of pediatric procedural sedations for diagnostic and minor therapeutic procedures performed outside the operating room has increased. Therefore, we established a specialized interdisciplinary team of pediatric anesthesiologists and intensivists (Children’s Analgosedation Team, CAST) at our tertiary-care university hospital and retrospectively analyzed the first year after implementation of the CAST. Within one year, 784 procedural sedations were performed by the CAST; 12.2% of the patients were infants <1 year, 41.9% of the patients were classified as American Society of Anesthesiologists (ASA) grade III or IV. Most children received propofol (79%) and, for painful procedures, additional esketamine (48%). Adverse events occurred in 51 patients (6.5%), with a lack of professional experience (OR 0.60; 95% CI 0.42−0.81) and increased propofol dosage (OR 1.33; 95% CI 1.17−1.55) being significant predictors. Overall, the CAST enabled safe and effective procedural sedation in children outside the operating room.

The relationship between the effect-site concentration of propofol and sedation scale in children: a pharmacodynamic modeling study

Background

Continuous infusion of propofol has been used to achieve sedation in children. However, the relationship between the effect-site concentration (C_e) of propofol and sedation scale has not been previously examined. The objective of this study was to investigate the relationship between the C_e of propofol and the University of Michigan Sedation Scale (UMSS) score in children with population pharmacodynamic modeling.

Methods

A total of 30 patients (aged 3 to 6 years) who underwent surgery under general anesthesia with propofol and remifentanil lasting more than 1 h were enrolled in this study. Sedation levels were evaluated using the UMSS score every 20 s by a 1 μg/mL stepwise increase in the C_e of propofol during the induction of anesthesia. The pharmacodynamic relationship between the C_e of propofol and UMSS score was analyzed by logistic regression with nonlinear mixed-effect modeling.

Results

The estimated C_e50 (95% confidence interval) of propofol to yield UMSS scores equal to or greater than n were 1.84 (1.54–2.14), 2.64 (2.20–3.08), 3.98 (3.66–4.30), and 4.78 (4.53–5.03) μg/mL for n = 1, 2, 3, and 4, respectively. The slope steepness for the relationship of the C_e versus sedative response to propofol (95% confidence interval) was 5.76 (4.00–7.52).

Conclusions

We quantified the pharmacodynamic relationship between the C_e of propofol and UMSS score, and this finding may be helpful to predict the sedation score at the target C_e of propofol in children.

Trial registration

http://www.clinicaltrials.gov (No.: NCT03195686, Date of registration: 22/06/2017).

Evaluation of the safety of using propofol for paediatric procedural sedation: A systematic review and meta-analysis

Propofol is one of the most widely used drugs for paediatric procedural sedation owing to its known advantages, but some concerns remain regarding respiratory and/or cardiac complications in patients receiving propofol. Although a considerable number of randomised controlled clinical trials (RCTs) have been conducted to compare it with other sedative agents or opioids for children undergoing various procedures, propofol is still being used off-label for this indication in many countries. We performed a systematic review and meta-analysis of those RCTs to provide an overall summation of evidence that can potentially be considered for further regulatory decisions, including reimbursement policies. We searched for RCTs in MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from their inception to January 31, 2018. Our meta-analysis of 30 RCTs confirmed that propofol sedation had advantages in recovery time when compared with other drugs, without excessive concerns for cardiovascular or respiratory adverse events. Its safety profile regarding coughing, nausea or vomiting, and emergence delirium was also similar to that of other drugs. The overall evidence suggests that propofol sedation for paediatric procedures should be considered more positively in the context of regulatory decisions.

Propofol Sedation by Pediatric Gastroenterologists for Endoscopic Procedures: A Retrospective Analysis

Background: There is a substantial literature on the favorable outcome of propofol administration by non-anesthesiologists for endoscopy in adults; however, very few data are currently available on propofol sedation by pediatric gastroenterologists. Aims: to evaluate the safety of propofol sedation by pediatric gastroenterologists. Methods: A retrospective chart review of all children who were sedated by pediatric gastroenterologists in three Northern Israeli hospitals over a 4 years period Demographic and medical characteristics and any data regarding the procedure were extracted from patient's records. The main outcome measurements were procedure completion and reported adverse events. Results: Overall, 1,214 endoscopic procedures for were performed during this period. Complete data was available for 1,190 procedures. All children sedated by pediatric gastroenterologists were classified as ASA I or II. Propofol dosage (in mg/kg) inversely correlated with patient age. The younger the child the higher the dose needed to reach a satisfactory level of sedation (r = -0.397, p < 0.001). The addition of fentanyl significantly decreased propofol dosage needed to provide optimal sedation, p < 0.001. Nine (0.7%) reversible adverse events were reported. All the procedures were successfully completed and all patients were discharged home. Conclusions: We conclude that our approach is safe in children as it is in adults and can be implemented for children with ASA I, II.

Verification of propofol sulfate as a further human propofol metabolite using LC-ESI-QQQ-MS and LC-ESI-QTOF-MS analysis

BACKGROUND

Propofol (2,6-diisopropylphenol) is a water-insoluble, intravenous anesthetic that is widely used for the induction and maintenance of anesthesia as well as for endoscopic and pediatric sedation. After admission, propofol undergoes extensive hepatic and extrahepatic metabolism, including direct conjugation to propofol glucuronide and hydroxylation to 2,6-diisopropyl-1,4-quinol. The latter substance subsequently undergoes phase II metabolism, resulting in the formation of further metabolites (1quinolglucuronide, 4quinolglucuronide and 4quinol-sulfate). Further minor phase I propofol metabolites (2-(ω-propanol)-6-isopropylphenol and 2-(ω-propanol)-6-isopropyl-1,4-quinol)) are also described. Due to its chemical structure with the phenolic hydroxyl group, propofol is also an appropriate substrate for sulfation by sulfotransferases.

METHODS

The existence of propofol sulfate was investigated by liquid chromatography electrospray ionization triple quadrupole mass spectrometry (LCESIQQQ-MS) and liquid chromatography electrospray ionization quadrupole time-of-flight mass spectrometry (LCESI-QTOF-MS). A propofol sulfate reference standard was used for identification and method development, yielding a precursor at m/z 257 (deprotonated propofol sulfate) and product ions at m/z 177 (deprotonated propofol) and m/z 80 ([SO3]-).

RESULTS

Propofol sulfate - a further phase II metabolite of propofol - was verified in urine samples by LC-ESI-QQQ-MS and LC-ESI-QTOF-MS. Analyses of urine samples from five volunteers collected before and after propofol-induced sedation verified the presence of propofol sulfate in urine following propofol administration, whereas ascertained concentrations of this metabolite were significantly lower compared with detected propofol glucuronide concentrations.

CONCLUSIONS

The existence of propofol sulfate as a further phase II propofol metabolite in humans could be verified by two different detection techniques (LCESIQQQ-MS and LC-ESI-QTOFMS) on the basis of a propofol sulfate reference standard. Evaluation of the quantitative analyses of propofol sulfate imply that propofol sulfate represents a minor metabolite of propofol and is only slightly involved in human propofol clearance.

What Works and What's Safe in Pediatric Emergency Procedural Sedation: An Overview of Reviews

BACKGROUND

Sedation is increasingly used to facilitate procedures on children in emergency departments (EDs). This overview of systematic reviews (SRs) examines the safety and efficacy of sedative agents commonly used for procedural sedation in children in the ED or similar settings.

METHODS

We followed standard SR methods: comprehensive search; dual study selection, quality assessment, data extraction. We included SRs of children (1 month to 18 years) where the indication for sedation was procedure-related and performed in the ED.

RESULTS

Fourteen SRs were included (210 primary studies). The most data were available for propofol (six reviews/50,472 sedations) followed by ketamine (7/8,238), nitrous oxide (5/8,220), and midazolam (4/4,978). Inconsistent conclusions for propofol were reported across six reviews. Half concluded that propofol was sufficiently safe; three reviews noted a higher occurrence of adverse events, particularly respiratory depression (upper estimate 1.1%; 5.4% for hypotension requiring intervention). Efficacy of propofol was considered in four reviews and found adequate in three. Five reviews found ketamine to be efficacious and seven reviews showed it to be safe. All five reviews of nitrous oxide concluded it is safe (0.1% incidence of respiratory events); most found it effective in cooperative children. Four reviews of midazolam made varying recommendations. To be effective, midazolam should be combined with another agent that increases the risk of adverse events (upper estimate 9.1% for desaturation, 0.1% for hypotension requiring intervention).

CONCLUSIONS

This comprehensive examination of an extensive body of literature shows consistent safety and efficacy for nitrous oxide and ketamine, with very rare significant adverse events for propofol. There was considerable heterogeneity in outcomes and reporting across studies and previous reviews. Standardized outcome sets and reporting should be encouraged to facilitate evidence-based recommendations for care.

Procedural sedation and analgesia in pediatric patients

A spectrum of conditions requires sedation and analgesia in pediatric population. Ineffective treatment of pain may result in physiological and behavioral responses that can adversely affect the developing nociceptive system. The recognition of pain in children can be facilitated by different pain scales. This article reviews the procedural sedation and analgesia (PSA) practices in children along with pharmacology of the drugs used for this purpose.