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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, zed@interchange.ubc.ca

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

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