BMC Emergency Medicine Journal Club - PowerPoint PPT Presentation

1 / 41
About This Presentation
Title:

BMC Emergency Medicine Journal Club

Description:

Propofol has recently gained increased ... Purposeful response to verbal or tactile stimuli ... Propofol has properties that make it ideal for use in the ED ... – PowerPoint PPT presentation

Number of Views:380
Avg rating:3.0/5.0
Slides: 42
Provided by: markb91
Category:

less

Transcript and Presenter's Notes

Title: BMC Emergency Medicine Journal Club


1
BMC Emergency MedicineJournal Club
  • State of the Art Propofol Use in the ED
  • March 2009

2
Todays Agenda
  • PROPOFOL State-of-the-Art
  • Gina Lopez
  • Scott Dresden

BMC EM Journal Club
BMC EM Journal Club
3
Propofol
  • Milk of amnesia
  • C12H18O
  • DiprivanTM
  • DI-isoPRopyl IV Anesthetic

4
Propofol
  • Ingredients
  • 1 propofol
  • 10 soybean oil
  • 1.2 purified egg phospholipid
  • 2.25 glycerol
  • Action sites
  • GABA-A ? Glycine ? Endocannabinoid ?

5
BMC Emergency MedicineJournal Club
  • State of the Art Propofol Use in the ED
  • Scott M. Dresden, MD

6
CJEM 2007 9 421

7
Background
  • Propofol has recently gained increased attention
    for procedural sedation and analgesia in the ED
  • Rapid onset, smooth, rapid recovery
  • May lead to hypotension, apnea

8
Objective
  • Evaluate efficacy, safety, and patient
    satisfaction with the use of propofol for
    procedural sedation, analgesia in the ED

9
Methods
  • Prospective observational study
  • Enrollment 113 consecutive patients receiving
    propofol for procedural sedation
  • December 2003-November 2005

10
Methods
  • Vancouver General Hospital
  • 700 bed adult tertiary referral centre
  • Affiliated with University of British Columbia
  • 62,000 ED visits/year

11
Methods
  • Protocol 3 people in room during sedation
  • Attending EM physician
  • Nurse
  • Respiratory Therapist
  • 0.25-0.5mg/kg propofol IV over 60 seconds
  • 10-20mg/min IV until adequate sedation
  • IV lidocaine and/or fentanyl permitted

12
Patient Characteristics
13
Key Results
  • Efficacy
  • 90 of procedures were successful
  • Mean recovery time 7.6 mins (SD 3.4)
  • Safety
  • 1 patient with emesis and desaturation
  • 9 patients with insignificant hypotension
  • No major complications

14
Key Results
  • Patient Satisfaction

15
Authors Conclusion
  • A standardized protocol for procedural sedation
    and analgesia with propofol in the ED is safe and
    effective with high patient and physician
    satisfaction.

16
Strengths of Article
  • Standardized protocol
  • Clearly defined rolls
  • Same bolus and maintenance doses
  • Consecutive patients selected
  • Clearly written and well organized

17
Limitations of Article
  • Not comparative
  • Small sample size
  • Variability of fentanyl administration
  • Did complicationsoccur with combo?
  • Post procedurepain?

18
Further Questions
  • How many procedures were done using other
    sedatives?
  • How many different attending physicians were
    involved in the study?
  • Who recorded the data?
  • Few complications due to low dose or
    standardized protocol?

19
Final Comments
  • Strong article, easy to read NO STATS
  • Objectives clearly stated and met
  • Conclusions supported by their data
  • Results convincing that propofol can be safely
    used in the ED with proper adherence to
    protocol

20
Yay Canada
  • Written by Canadian Pharmacists
  • In 2 languages

21
Questions?
22
BMC Emergency MedicineJournal Club
  • State of the Art Propofol Use in the ED
  • Gina Lopez, MD, MPH

23
Ann Emerg Med. 2008 52(4) 392-398
24
Why should I care what they say?
  • Dr. Steven Green
  • 47 articles from 2002 present
  • 24 related to conscious sedation
  • Dr. Baruch Krauss
  • 34 articles from 2002 present
  • 26 related to conscious sedation
  • Focus on safety considerations
  • Pioneers in characterizing ketamine use for
    conscious sedation in pediatrics

25
ASA Definitions of General Anesthesia and Levels
of Sedation/Analgesia
Moderate Sedation
26
Background
  • In the ED, we utilize conscious sedation for a
    wide range of procedures
  • Propofol has properties that make it ideal for
    use in the ED
  • 28 published series on ED propofol in 3811 pts
    showing it to be safe effective
  • Historically, there have been many barriers to
    propofol use in the ED

27
Objective
  • Identify and discuss the most common barriers of
    propofol use in the ED
  • No Null Hypothesis

28
Methods
  • Type of paper Commentary
  • Written by two emergency medicine physicians
  • Systematic review of barriers to ED propofol use

29
Outline
  • Terminology nonanesthesiolgist
  • Who decides who can use propofol?
  • Criticisms and Rebuttals
  • Financial concerns

30
Nonanesthesiologist
  • In 2002, the ASA noted practice guidelines for
    sedation and analgesia by nonanesthesiolgists
  • - Term never defined
  • - There is a spectrum of skills
  • ARGUMENT Propofol use should be based on skills
    not this arbitrary dichotomy

31
Who Decides Who Uses Propofol?
  • Specialty guidelines may be cited in litigation
    but no authority on their own
  • Joint Commission set basic standards
  • Hospital Leadership true authority in setting
    sedation guidelines
  • May delegate responsibility to anesthesia chiefs
  • Often an interdisciplinary sedation committee

32
Criticisms Rebuttals
33
Semantics
  • Product Labeling
  • ASA/AANA Joint Statement
  • ASA Deep Sedation Statement
  • And
  • Propofol oversedation is general anesthesia
  • Deep sedation ? general anesthesia ED physician
    qualified to rescue patient if necessary

34
Safety Concerns
  • Respiratory Depression
  • Aspiration
  • Not supported by evidence
  • No propofol-specific antagonist
  • Not necessary since such short half-life
  • Technically difficult
  • Oversedation
  • ED physicians are qualified to do RSI, manage
    airways and monitor levels of sedation

35
Financial Concerns
  • Poachers and Dabblers
  • Do anesthesiologists really want to come down to
    the ED for our conscious sedation?
  • The ED isnt a great source of revenue

36
Authors Conclusion
  • Propofol is safe for conscious sedation when
    supervised by a residency trained emergency
    physician
  • Emergency physicians should become represented on
    the hospital sedation committee establishing safe
    protocols for the use of propofol for conscious
    sedation
  • "Deep sedation using propofol is rapidly evolving
    into an essential emergency medicine skill, and
    emergency physicians must overcome barriers to ED
    propofol use for the benefit of our patients"

37
Strengths of Article
  • Written by two of the leaders in conscious
    sedation in emergency medicine
  • Systematic approach to the most common barriers
  • Cites the evidence to support the safe use of
    propofol in the ED

38
Limitations of Article
  • Its just a commentary
  • Biased
  • Written by two emergency medicine physicians
  • 8 of 31 citations include one of the authors

39
Further Questions
  • What exactly does the latest ASA statement on
    propofol use outside the operating room say?
  • What is the safety data in the anesthesia
    literature on propofol use for conscious sedation?

40
Final Comments
  • Nice basic overview of the issues from the ED
    perspective
  • "Deep sedation using propofol is rapidly
    evolving into an essential emergency medicine
    skill, and emergency physicians must overcome
    barriers to ED propofol use for the benefit of
    our patients
  • This conclusion is a stretch because doesnt
    really present evidence to support why using
    propofol is essential or how it will benefit
    our patients

41
Upcoming Journal Clubs
  • April 14 Infectious Disorders
  • Megan Salinas (EM2)
  • Jason Delong (EM1)
  • May 12 Musculoskeletal Disorders Levenberg and
    Stanton
  • June 9 Nervous System Disorders Sullivan and
    Horesji

BMC EM Journal Club
BMC EM Journal Club
Write a Comment
User Comments (0)
About PowerShow.com