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PEM physicians can safely and effectively administer propofol.

To the Editors: We read with interest the article by Wheeler et al in the December 2003 issue of your journal. We commend the authors on an important contribution to the growing evidence in support of the use of propofol outside the traditional operating room (OR) setting. We were, however, deeply concerned that the authors’ conclusions did not accurately reflect the available evidence. They stated, ‘‘Consistent with the available literature, we found propofol to provide safe and effective sedation with a rapid onset and recovery, making it the ideal anesthetic agent to facilitate the performance of elective medical procedures in both the PICU and pediatric sedation unit setting.’’ They further added, ‘‘Given its potential to cause cardiorespiratory depression, however, the use of propofol outside the OR setting should be limited to anesthesiologists and pediatric intensivists.’’ As the authors had indicated, data from retrospective studies are fraught with several limitations. In particular, it is difficult to draw any meaningful comparative conclusions, in the presence of variable populations; inconsistent definitions of adverse events like respiratory depression; a wide range of indications; and the variable use of adjunctive agents, including supplemental oxygen. Ironically, of the 21 cited references (including the index article) only 4 had a rigorous prospective controlled study design to permit any reasonable conclusion about safety and efficacy of propofol use outside the OR setting. Of the 4 aforementioned studies, 2 were conducted by pediatric emergency medicine investigators. Yet, we observed that there was a conspicuous omission of any discussion about the use of propofol in pediatric emergency departments. Incidentally, the Seigler et al study setting was incorrectly mentioned as emergency department instead of the pediatric intensive care unit in the discussion section of the Wheeler et al paper while being correctly mentioned in Tables 2 and 3. We would also like to point out that the indications for use of propofol for procedural sedation in the pediatric emergency department are vastly different from those listed by Wheeler et al. These include, but not limited to, orthopedic manipulation, sexual abuse examinations, abscess drainage, cardioversion, and complex laceration repairs. We would, therefore, like to take this opportunity to update the readership of your journal on the evidence in support of the use of propofol by pediatric emergency medicine physicians. As part of a sedation service that is run by our pediatric emergency medicine division here at Le Bonheur Children’s Medical Center, we have had extensive experience in the use of propofol over the last 5 years, both in our pediatric emergency department and radiology suites. Based on the references cited by Wheeler et al and the additional evidence presented, we strongly believe that pediatric emergency medicine physicians can administer propofol to facilitate procedures safely and effectively. As the readership of this journal is aware, the pediatric emergency department patient represents a unique subset distinct from the OR and pediatric intensive care unit population. Airway management is an integral part of daily practice of emergency medicine. Given the uncertain nil per os status, potential for cervical spine and orofacial injury in trauma patients and ‘‘unexpected’’ (nonelective) nature of these clinical scenarios, our patients frequently possess a higher risk profile and American Society of Anesthesiology class. While we fully acknowledge and respect the airway skills of the pediatric intensivist and anesthesiologist, we would argue that the skill set required of pediatric emergentologists is unique. Moreover, the less than 1% rate of failed intubations by emergency department providers from the national emergency airway registry is also comparable to the published ASA data on failed OR intubations. We are not aware of similar data from the pediatric critical care literature. In summary, we believe that restricting therapeutic interventions, including the use of propofol, to a select group of specialties, as suggested by the authors, will deprive our patients of valuable advances in the science of sedation. Ultimately, we will be judged not by who or what type of providers we are but by the care we deliver to relieve pain and suffering in our most vulnerable population, our children.