EM-3. Propofol for deep procedural sedation in the pediatric population.

This study investigated the incidence of complications with increasing experience using propofol for deep procedural sedation by emergency physicians in a community emergency department. During the investigation of the first 100 pediatric patients (age 18 months to 12 years) to receive propofol for deep procedural sedation in our emergency department a complication incidence of 9% was noted. The current study investigates the incidence of complications in the next 100 patients. Our theory was that the incidence of complications would decrease as familiarity with the drug increased. Data were collected prospectively on the number 101 to 200 pediatric patients that had undergone deep procedural sedation with propofol in our community emergency department. Patients were given propofol in a titrated dose at the discretion of the emergency physician until the desired level of sedation was obtained. The drug was given without regard to time of last oral intake. Vital signs and pulse oximetry were recorded during the procedure and until recovery. The nurses recorded complications. Decrease of systolic blood pressure of 20% of the presedation level, hypoxemia of pulse oximetry <90%, respiratory depression requiring assisted ventilation or intubation, aspiration, airway obstruction, bradycardia, or anesthesia consultations were considered complications. Case data, adverse events, sedation duration, and recovery time were recorded into a database. Over the study period, patients received propofol for orthopedic reduction (72%), lumbar puncture (10%), laceration repair (17%) and ocular examination (1%). All procedures were completed successfully. Mean dose of propofol was 2.7 mg/kg (range, 0.4 to 7.9 mg/kg). Patient ages ranged from 9 months to 12 years of age; 92 patients were ASA physical class status I and 8 were ASA class II. Of the ASA class II patients there were 4 diabetics, 4 patients with asthma, and 1 patient with sickle cell anemia; 98 patients were sedated to level IV and 2 were sedated to level III> Transient hypoxia (SBP <90 mm Hg) occurred in 2 patients. In 2 patients the hypoxia resolved with airway repositioning and did not recur. One patient suffered respiratory depression that required bag-mask assistance for 1 minute. No patients developed hypotension, required intubation, aspirated, suffered airway obstruction, or required anesthesia consultation. Mean procedure time was 12 minutes (range 2 to 42 minutes). Mean sedation time was 27 minutes (range 7 to 55 minutes). Mean time to awake post procedure was 5 minutes (range 2 to 13 minutes). This incidence of complications decreased from 7% to 3% with increasing experience using propofol for deep procedural sedation. In the first 100 patients, 3 developed hypotension, 4 developed transient hypoxia, and 2 required assisted ventilation. In the next 100 patients, there were only 3 complications. This revealed a decrease in the complication rate from 7 to 1%, indicating as the familiarity with propofol increased the complication rate improved. The most dreaded complications of aspiration or need for intubation have not occurred in the 200 patients studied to date.

Mitch Charles, MD, Barry Walling, MSIII, and Paulette Wehner, MD. Department of Emergency Medicine, Marshall University School of Medicine, Cabell Huntington Hospital, Huntington, WV.