No adverse outcomes occurred among 1000 adult propofol procedural sedation episodes.

To determine the safety of propofol for emergency department (ED) procedural sedation, researchers retrospectively applied a sedation adverse-event reporting tool to 1008 consecutive patients (age range, 15 to 97 years) who underwent procedural sedation at a single ED in the U.K. over a 5-year period. Sentinel events included oxygen saturation <75% for any length of time or <90% for more than 60 seconds, apnea lasting longer than 60 seconds, aspiration event, need for intubation, cardiovascular collapse, permanent neurologic disability, and death. Most patients were sedated for orthopedic procedures (77%) and cardioversion (9%). Monitoring included pulse oximetry, non-invasive blood pressure measurement, respiratory rate, and electrocardiography; nasal capnography was adopted near the end of the study period.

A total of 73 adverse events were reported: 11 sentinel, 34 moderate, 25 minor, and 3 minimal risk. Sentinel events included six episodes of prolonged hypotension (>60 seconds) requiring brief vasopressor support, and five episodes of hypoxia, all but one of which resolved with assisted ventilation. One patient with unstable ventricular tachycardia underwent cardioversion, vomited, and became hypoxic, necessitating intubation for airway protection and altered mentation. He was found to have a saddle pulmonary embolism and distal aortic thrombus; he survived to hospital discharge. No adverse outcomes related to procedural sedation were identified.

Comment: Several patients with sentinel adverse events had significant underlying medical comorbidities. Fortunately, no patients suffered any adverse outcomes related to the procedural sedation, but this study reminds us that proper monitoring, including capnography, and careful patient selection are crucial to ensure the safety of this procedure. Patients at high risk for adverse events, such as those with significant cardiopulmonary comorbidity, and those with difficult airways should be evaluated for possible sedation in the operating room.

Source: Journal Watch Emergency Medicine