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Three Part Question

In [patients requiring conscious sedation for short painful procedures] does [propofol compared with midazolam] give [shorter recovery times whilst being safe and effective]?

Clinical Scenario

A 35 year old man presents with a dislocated shoulder. You are about to undertake the reduction under sedation in the emergency department and wonder whether the use of a propofol infusion rather than boluses of midazolam would give effective sedation with shorter recovery time without compromising safety.

Search Strategy

Medline 1966-07/2001 using the Ovid interface.
{exp propofol/ OR "propofol".mp} AND {exp midazolam/ OR "midazolam".mp OR exp diazepam/ OR "diazepam".mp. OR exp lorazepam/ OR "lorazepam".mp. OR exp benzodiazepines/ OR "benzodiazepine$".mp.} AND {exp conscious sedation/ OR "sedation".mp OR exp manipulation, orthopedic/ OR "manipulation".mp OR "reduction".mp. OR exp dislocations/ OR "dislocation".mp. OR exp fractures, closed/ OR exp fractures/ OR "fractures".mp. OR exp abscess/ OR "abscess".mp. OR "incision".mp. OR exp electric countershock/ OR "cardioversion".mp.} AND maximally sensitive RCT filter LIMIT to human AND English language.

Search Outcome

220 papers were identified of which one compared the use of propofol with midazolam in the emergency department. A further 3 papers compared the two agents in other settings for conscious sedation for short procedures. Whilst not directly applicable to the emergency department these have been included as they are applicable to the three part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Gupta A et al, 1990, Sweden	30 patients undergoing cardioversion Randomised to midazolam or propofol or thiopentone	PRCT	Sedation and recovery times	Shorter time to sedation and to recovery with propofol vs midazolam (p<0.05).	Not emergency setting Unblinded Sedation titrated to loss of eyelash reflex (i.e. not conscious sedation)
			Physiological observations	Decreased BP in propofol group, equal incidences of desaturation. Apnoea requiring assisted ventilation in 3 of propofol group.
Pratila MG et al, 1993, USA	90 patients undergoing central venous line insertion Randomised midazolam or propofol boluses (PB) or infusion (PI)	PRCT	Physiological observations	No significant cardiovascular adverse events. SaO2 drop 2.2% with propofol (PB) vs 0.3% midazolam (p<0.04)	Not emergency setting Unblinded
			Recovery time	Recovery time shorter with propofol, 8 mins (PI) and 14 mins (PB) vs 25 mins with midazolam (p<0.05)
			Complications	Apnoea in 3 of PB group, none required assisted ventilation
Parworth LP et al, 1998, USA	57 patients undergoing 3rd molar tooth extraction Randomised to midazolam or propofol	PRCT	Sedation efficiency	Propofol group less cooperative (p=0.02).	All patients given fentanyl Not emergency setting Unblinded Recovery time not assessed.
			Physiological observations	2 in midazolam group vs 1 in propofol group were apnoeic for >20 secs, none required assisted ventilation. No significant cardiovascular adverse events.
Havel CJ Jr. et al, 1999, USA	89 children aged 2-18 with isolated limb injury requiring reduction in ED Randomised to midazolam or propofol	PRCT	Complications	No differences in rates of hypoxia, hypotension. No clinically significant complications.	All patients given morphine. Small numbers to detect significant complications. Incomplete follow up after discharge
			Sedation scores	Sedation scores equivalent between groups.
			Recovery time	Recovery in 14.9 mins with Propofol vs 76.4 mins with Midazolam (p< 0.001)

Comment(s)

The routine use of propofol for sedation by non-anaesthetists is not currently accepted practice. Sedation by any means has inherent risks and there must be adequate resuscitation equipment and skilled staff available. Adverse events will occur more quickly with propofol than with midazolam, but they will also resolve more quickly. The above papers confirm the efficacy and safety of propofol for conscious sedation and the shorter onset and recovery times are a major advantage.

Editor Comment

A recent paper supporting the use of Propofol has been published that needs inclusion into this BET. Taylor D et al; Propofol vs Midazolam/Fentanyl for reduction of anterior shoulder dislocation. Acad Emerg Med 2005;12:13-19

Clinical Bottom Line

From the available evidence it appears that sedation with propofol in the Emergency Department is safe, effective and dramatically reduces recovery times. The use of this agent should be considered.

References

1. Gupta A, Lennmarken C, Vegfors M, et al. Anaesthesia for cardioversion. A comparison between propofol, thiopentone and midazolam. Anaesthesia 1990;45(10):872-5.
2. Pratila MG, Fischer ME, Alagesan R, et al. Propofol versus midazolam for monitored sedation: a comparison of intraoperative and recovery parameters. J Clin Anesth 1993;5(4):268-74.
3. Parworth LP, Frost DE, Zuniga JR, et al. Propofol and fentanyl compared with midazolam and fentanyl during third molar surgery. J Oral Maxillofac Surg 1998;56(4):447-53.
4. Havel CJ Jr., Strait RT, Hennes H. A clinical trial of propofol vs midazolam for procedural sedation in a pediatric emergency. Acad Emerg Med 1999;6(10):989-97.