Propofol for procedural sedation

[Arch Guillotti]

Also I don't do paralysis when I do sedation. I ABSOLUTELY agree it would help with a hip dislocation. This is usually why I call anesthesia and Ortho takes them to the OR... so they can do anesthesia and paralyze the patient and get the hip in.

Could an EP do this safely? Sure. I do find it playing with fire, however. Certainly you would need two providers with one solely doing the... anesthesia.

I have staffed hundreds of dislocated hip reduction. Only a couple required paralysis and even then it didn’t always work.

“Usually” sending them to the OR is a tremendous waster.

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[southerndoc]

Yeah, all of our sedations in the ED are "deep". Most of these procedures just can't be completed otherwise. I don't know what the answer is regarding hospital credentialing but I don't think anesthesia should feel any sort of turf infringement. I mean, we can't do anything near what you guys can do. It's not like we're going to be requesting anesthesia machines and sevo anytime soon for the ED. You guys probably have no idea how frequently we are required to perform sedation in the ED. Trust me when I say you don't want to be consulted for this every time. It's a complete pain in the ass. That being said, I'd gladly give up all my "moderate sedation" privileges if anesthesia could be consulted to the ED for this kind of stuff 24/7/365. I hate doing sedation these days. It grinds things to a halt and locks me in a room for half an hour while anything could be coming through the ambulance bay.

Anesthesia would have a fit if they had to come to the ER for every sedation. I'm still in disbelief that a lot of hospitals still don't let their ER docs use propofol.

 

[Janders]

I have staffed hundreds of dislocated hip reduction. Only a couple required paralysis and even then it didn’t always work.

“Usually” sending them to the OR is a tremendous waster.

I do NOT usually send them to the OR. I do send them to the OR if paralysis is needed as I don’t push sux in my ED unless I am intubating.

I try 95% of hip dislocations myself. Occasionally they are so moribund I’m not going to sedate them.

I succeed 80-90+% of the time. This is by myself and without Ortho or anesthesia.

If I fail, I call Ortho and they call anesthesia and it seems universally they go to the OR and paralyze.

 

[Mount Asclepius]

I have staffed hundreds of dislocated hip reduction. Only a couple required paralysis and even then it didn’t always work.

“Usually” sending them to the OR is a tremendous waster.

Thank you for indirectly illustrating my point. Hospitals put unnecessary limits on EP scope of practice through credentialing when it comes to procedural sedation, but then criticize us for not being able to perform the work of two physicians (Orthopedic Surgery and Anesthesiology) in the ED simultaneously with one arm tied behind the back. If everyone knew the sheer number of things we are expected to handle in the ED with less than adequate tools, then we wouldn’t receive near the level of unwarranted criticism as a speciality.

 

[GassYous]

We do - when it’s appropriate. But this is a thread that specifically asked about how we choose to employ propofol. That doesn’t mean that we can’t or won’t use other agents when appropriate. When there is a thread on the anesthesia subforum asking about how someone uses isoflurane, do EPs wander over and start asking, “Why don’t you guys ever use more laughing gas?”

Many of our procedures are brief, lasting under 2 minutes, and propofol is more appropriate because it is associated with shorter recovery and ED length of stay. Propofol is also more ideal for those patients who need deep sedation or general anesthesia for under 5 minutes than versed/fent.

You can choose to employ propofol along with versed or fentanyl or even both. It decreases the dose of propofol needed for proper sedation. You're welcome.

 

[TooMuchResearch]

You can choose to employ propofol along with versed or fentanyl or even both. It decreases the dose of propofol needed for proper sedation. You're welcome.

They will generally have had good doses of opioids leading up to the sedation. The only hips I haven't gotten back in had retention rings or whatever they're called.

I definitely don't use paralytics and endotracheal tubes for ED procedural sedation though.

 

[BoardingDoc]

he only hips I haven't gotten back in had retention rings or whatever they're called.

Dual mobility cup hips? The one where there's a plastic cup that sits against the acetabular liner and the ball from the prosthesis sits in that instead of directly against the liner?

I've only had one hip dislocation with one of those. I also have a 99% success rate of reducing hips in the ED over the past 10 years. Guess which one I didn't get?

To be fair, when I called Ortho after and lamented the loss of my perfect streak his verbatim response was "this doesn't count. You were never going to get one of these back in outside of the OR."

 

[ShockIndex]

I figure that it’s probably worth posting the ACEP Clinical Policy on Propofol Use in the ED if for no other reason it has a reasonable collection of relevant articles on the topic.

ACEP SSO Service

One paper that I find particularly relevant is Schick et al Acad Emerg Med 2018. This trial showed that it is virtually impossible to accurately target a sedation level with propofol, many patients who we want to moderately sedate get deeply sedated, and the median dose difference between the 2 levels of sedation was trivial. Notice the relatively small total median doses of propofol give that was 1.4 and 1.8 for MS and DS, respectively. The IQR was only about 1 mg/kg.

This goes back to my original point that while propofol is a great drug, many hospitals still have credentialing parameters that do not reflect the contemporary use of the drug in EM practice. To the extent that some progressive hospitals have updated EP credentials to include deep or “procedural” sedation (ie any level of sedation needed up to but excluding general anesthesia), I’m still not sure that these liberal privileges encapsulate our practice when some of our colleagues in this thread are targeting apnea for some joint reductions. Moreover, there is a very good chance that we are practicing in an “evidence free zone” if we have advanced our practices to at least tolerating high incidences of general anesthesia since none of the ED studies on propofol addressed this level of anesthesia (and good luck getting such a study through an IRB).

Finally, this notion of giving paralytics to non-intubated, moderately sedated patients to help with reductions…I literally have no words.

 

[ShockIndex]

We don't intubate for procedural sedation.
That said, I just keep bolusing propofol until it's the right dose.
For hips, that often means apnea.

I agree and would add that EPs should not be intentionally intubating for procedures in the ED. This almost always will cross over to the realm of providing general anesthesia services. I suspect that very few EPs are credentialed for this since the recovery and extubation process is outside the scope of most EPs training.

I’ve been in several institutional conversations as an EP and intensivist where this has become an issue. The classic example is a UGI bleeder that GI wants intubated for the endoscopy in the ED or ICU rather than take them to the OR or endo suite where anesthesia would run the case as they see fit. We determined that as EPs and intensivits we will intubate the patient for airway protection. but not extubate immediately after the procedure. Our logic is that airway threats from re-bleeding are not sufficient addressed by a single EGD, and patients who are sufficiently sick to need emergent EGDs warrant further observation in the ICU while intubated. This logic was deemed to be both safer for the patients and adherence to our privileges to intubate for airway protection but not to provide general anesthesia services. Similar logic can be applied to almost any ICU or ED patients who needs an airway for general anesthesia levels of sedation to accomplish a procedure.

 

[TeddyBoomBoom]

I’m just amazed that we’re even having a discussion about:

A) ER docs electively intubating patients for urgent but not critical or even emergent procedures to be done in the ED

B) ER docs pushing paralytics in non-intubated patients to fascilitate procedures

This is just crazy to me. ABEM here btw.

🤷

 

[TooMuchResearch]

Yes that's probably what it was.
The patient wanted me to speak with ortho, they told me to go for it, and after the failure called me again and said "just looked at the xray, don't bother trying, I'll take to the OR."
You know what? That's a case of me not knowing what I didn't know. Now I know.

 

[TooMuchResearch]

I’m just amazed that we’re even having a discussion about:

A) ER docs electively intubating patients for urgent but not critical or even emergent procedures to be done in the ED

B) ER docs pushing paralytics in non-intubated patients to fascilitate procedures

This is just crazy to me. ABEM here btw.

There is literally an entire specialty for this. We're not it.