JC: ED physicians are not Propofol Assassins – St.Emlyn’s

propofol nott vet school flckrIf you’ve never listened to the rant by Cliff Reid on Propofol then you should do so now. It’s a great description of why propofol is a rather ‘courageous’ agent for RSI in the ED and critical care unit. It’s truly #FOAMed gold and you should give it the time it deserves. However, it might just make you stop and think about the dichotomy that exists in people like me who baulk at the idea of propofol for RSI, but who advocate the use of propofol for sedation.

Ed – but sedation to anaesthesia is really just a continuum isn’t it?

Well, yes! Give enough propofol and you get anaesthesia so some anaesthetists may think that we really don’t have a cogent argument with  a clear paradox around the use of propofol. This argument has raged for years to be honest, with anaesthetists and EPs locked in battle over the internet on the use of ED sedation. What we could do with is, is some evidence and thankfully we have people like Newstead et al from the Royal Devon hospital in the UK to collect and publish some data in the British Journal of Anaesthesia. This is good stuff and it is of note that they chose, and achieved publication in an anesthetic journal as opposed to the EM literature where many previous studies have appeared. It’s good to see the data taken to our anaesthetic colleagues and great that the journal chose to publish it.

So, the abstract from the paper is below, but you should really read the full paper here if you have permissions.

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[DDET So what kind of paper is this?]

This is essentially an audit of 1008 cases of propofol use in the emergency department at a single centre. The Royal Devon & Exeter hospital is a medium sized ED for the UK in a fairly rural setting (for the UK at least). In my opinion it has a fairly young and dynamic group of consultants who have done some great research in the past such as the elbow extension rule published in the BMJ. This paper looks at use of sedation using propofol in the ED with a focus on complication rates. Complications have always been the concern in the use of propofol so it seems reasonable to focus on this. This is not a comparative study as propofol seems to be the sedation agent of choice in this department, so this study does not tell us what the best sedation agent is. Rather it tells us about propofol use in the ED, and since that is the controversial area that seems fair enough!

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[DDET Tell me about the patients]

It’s always important to look at the patient group to see whether it is like your own. Sadly the data available in the journal is fairly limited. The average age of patients was 58 but we know little else about demographics.

In terms of indication then there is a helpful chart showing that the majority of sedations were for MUAs, and of note 25% were for relocation of hip dislocations. That suggests a rather different cohort to that of Virchester which may reflect local age differences and perhaps differences in orthopaedic practice. In fact they performed more sedation for hips than shoulders. Clearly there are many reasons why that may be (Ed – Cunningham technique perhaps) but we are left guessing as to why….., but it does look like a different patient group to Virchester.

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[DDET So what is a complication anyway?]

I’m glad you asked. A complication to one person is an inconvenience to another so in studies of this kind we require some standardisation of what constitutes a complication. The use of the Society of Intravenous Anaesthesia scale is a reasonable choice in this regard as it can at least allow comparison with past and future studies in the same area.

My only comment in this is that the complication rate relates to events in process rather than events in outrcome. Complications are described in terms of aspects such as transient hypoxia and hypotension rather than events that have permanence for the patient. Whilst it is entirely valid to talk about complications in process they are clearly of differential importance to those leading to long term morbidity and mortality for patients.

[/DDET]

[DDET So what was the event rate?]

The authors identified 11 significant adverse events. 5 of hypoxia and 6 of hypotension. So that’s roughly 1% which may raise a little concern, but the detail of the events suggests that sedation did not contribute to any permanent morbidity or mortality and that’s important. Patients (and clinicians) are most interested in final outcomes and whilst some detail is lacking in the paper it would appear that the permanent complication rate is very low indeed.

The authors allude to concerns about overdosage beyond the recommended 0.5mg/Kg in the elderly as a cntributing factor for hypotension in the elderly.

[/DDET]

[DDET Any other concerns with this methodology?]

About 14% of patient records were missing and whilst the authors suggest that it is unlikely that a complication was missed in these patients we don’t know. This would affect the overall results (certainly increasing the confidence intervals) but perhaps not significantly.

The associated podcast featuring the senior author Gavin Lloyd – now missing 🙁alludes to a very tight and well monitored sedation protocol and training program. This is something to be applauded, but it may limit the transferability of the findings. The podcast is excellent and well worth a listen.[/learn_more][learn_more caption=”Where does this paper leave us?”] In our opinion this paper provides some evidence for the safety of propofol use by emergency physicians in a well supervised, well trained and apparently well motivated setting. Whilst not definitive (Ed- what paper ever is???), it supports the use of propofol by EPs in the UK and is it agrees with what we think at St.Emlyn’s – we love it (Ed – beware papers you agree with – it’s harder to spot the bias…….).

[/DDET]

So, in summary it’s great to see some more excellent research from the team in the SW of England. It’s a lovely place to visit and on the basis of this it appears to be quite a good place to dislocate your hip prosthesis…

 

2 Comments

  1. Andy Webster

    There is only one magic milk so why do we need to apply a sticker?

    Reply
    1. gasdoc2857

      Diazemuls? Though unlikely to be in a 20ml syringe. Then again, knowing some of the surgeons I work with……….

      Reply

Thanks so much for following. Viva la #FOAMed

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