Pain management and sedation/original research
Emergency Physician–Administered Propofol Sedation: A Report on 25,433 Sedations From the Pediatric Sedation Research Consortium

Presented at the 2010 Pediatric Academic Societies meeting, May 2010, Vancouver, British Columbia, Canada.
https://doi.org/10.1016/j.annemergmed.2011.03.008Get rights and content

Study objective

We describe the adverse events observed in a large sample of children sedated with propofol by emergency physicians and identify patient and procedure characteristics predictive of more serious adverse events.

Methods

We identified sedations performed by emergency physicians using propofol as the primary sedative, included in the Pediatric Sedation Research Consortium database from July 2004 to September 2008. We describe the characteristics of the patients, procedures, location, adjunctive medications, and adverse events. We use a multivariable logistic regression model to identify predictors of more serious adverse events.

Results

Of 25,433 propofol sedations performed by emergency physicians, most (76%) were performed in a radiology department. More serious adverse events occurred in 581 sedations (2.28%; 95% confidence interval 2.1% to 2.5%). There were 2 instances of aspiration, 1 unplanned intubation, and 1 cardiac arrest. Significant predictors of serious adverse events were weight less than or equal to 5 kg, American Society of Anesthesiologists classification greater than 2, adjunctive medications (benzodiazepines, ketamine, opioids, or anticholinergics), nonpainful procedures, and primary diagnoses of upper respiratory illness or prematurity.

Conclusion

We observed a low adverse event prevalence in this largest series of propofol sedations by emergency physicians. Factors indicating greater risk of more serious adverse events are detailed.

Introduction

Propofol sedation outside of the operating room is now commonplace, as documented by multiple studies in various clinical settings.1, 2, 3, 4, 5, 6 The largest of these, a 2009 report from the Pediatric Sedation Research Consortium,3 characterized 49,836 pediatric sedations for which propofol was used as the primary sedative. Emergency physicians supervised 36% of the cases in that report. Although there was no difference in reported respiratory events between anesthesiologists and other providers, outcomes by emergency physicians were not explicitly delineated.

Smaller studies suggest that propofol is more effective than other fast-acting sedatives, with a similar or superior adverse event profile.7, 8, 9 Documenting the safety profile of propofol by emergency physicians has been limited by small sample sizes, inconsistent definitions of adverse events, and the variability of patient populations. Severe adverse events, such as laryngospasm and aspiration, are so rare that their study requires extremely large samples.2, 3, 10, 11 Previous pediatric emergency department (ED) studies have reported adverse airway events ranging from 0.6% to 30% of propofol sedations, underscoring the importance of clear definitions.1, 4, 12, 13 Emergency physicians are increasingly called on to sedate outside the ED (eg, radiology, sedation services).14, 15, 16

Given the growing popularity of propofol administration by emergency physicians, it is important to accurately characterize the adverse event profile associated with its use by these providers.

We wished to describe the adverse events observed in a large sample of children sedated with propofol by emergency physicians and to identify patient and procedural factors that predict the more serious adverse events.

Section snippets

Study Design

We analyzed consecutive pediatric propofol sedations overseen by emergency physicians from the Pediatric Sedation Research Consortium database between July 2004 and September 2008.

Data Collection and Processing

The Pediatric Sedation Research Consortium data collection methodology has been detailed in a report of its first 30,000 sedations.17 The Pediatric Sedation Research Consortium data sharing group comprises 37 self-selected locations, including children's hospitals (both within and separate from general hospitals), and

Characteristics of Study Subjects

The Pediatric Sedation Research Consortium database recorded 123,938 sedations from July 2004 through September 2008, and of these, 25,469 primarily used propofol and were administered by emergency physicians. We excluded 36 subjects for being aged 21 years or older, leaving 25,433 for our study sample. Demographics and sedation characteristics are shown in Table 1, with most children relatively young (Figure). Of the 19,415 sedations that were performed in a radiology department, 17,602 were

Limitations

The limitations of the Pediatric Sedation Research Consortium database have been enumerated in various articles.3, 9, 17, 18 We have attempted to minimize coding variability by using largely objective endpoints with clear definitions and through group discussion at yearly Pediatric Sedation Research Consortium meetings. Though the rules of the database dictate strict institutional anonymity, a bias toward underreporting potentially embarrassing adverse event data could exist. We believe this to

Discussion

In this large sample of children sedated with propofol by emergency physicians, we observed a prevalence of adverse events that compares favorably with that of other sedatives commonly administered by emergency physicians and that of sedation administered by anesthesia providers. Our observed frequency of propofol-associated laryngospasm (0.11%) is less than that reported by Vespasiano et al5 (0.27%) in their intensive care setting. This Pediatric Sedation Research Consortium report included 1

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    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Financial support for the establishment of the Pediatric Sedation Research Consortium database was provided by a grant from the National Patient Safety Foundation.

    Supervising editor: Steven M. Green, MD

    Author contributions: MDM, ALB, and JPC conceived the study design and wrote the article. MDM and DJY performed data analysis. All authors contributed substantially to its revision. MDM takes responsibility for the paper as a whole.

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