ABSTRACT
Context: Propofol is a general anesthetic used in multiple clinical scenarios. Despite growing evidence supporting its use in palliative care, propofol is rarely used in palliative sedation. Reluctance toward the adoption of propofol as a sedative agent is often associated with fear of adverse events such as respiratory arrest. Objectives: We aimed to describe efficacy and safety of palliative sedation in refractory sedation with propofol using a protocol based on low, incremental dosing. Methods: A retrospective observational study featuring inpatients receiving sedative treatment with propofol in our palliative care unit in Madrid (Spain) between March 1, 2018 and February 28, 2023, following a newly developed protocol. Results: During the study period, 22 patients underwent sedation with propofol. Propofol was used successfully to control different refractory symptoms, mainly psychoexistential suffering and delirium. All patients had undergone previous failed attempts at sedation with other medications (midazolam or lemovepromazine) and presented risk factors for complicated sedation. All patients achieved satisfactory (profound) levels of sedation measured with the Ramsay Sedation Scale, but total doses varied greatly between patients. Most patients (17, 77%) received combined therapy with propofol and other sedative medications to harness synergies. The median time between start of sedation with propofol and death was 26.0 hours. No cases of apnea or death during induction were recorded. Conclusion: A protocol for palliative sedation with propofol based on low, incremental dosing, with the option of administering an initial induction bolus, shows excellent results regarding adequate levels of sedation, without observing apnea or respiratory depression. Our results promote the use of propofol to achieve palliative sedation in patients with refractory symptoms and risk factors for complicated sedation at the end of life.
ABSTRACT
ANTECEDENTES Y OBJETIVOS: El aumento de pacientes paliativos genera más situaciones de sedación paliativa complicada. Múltiples factores influyen en la dificultad para realizar una sedación: tolerancia farmacológica, interacciones medicamentosas, afrontamiento emocional... En situaciones de resistencia a fármacos sedantes habituales se precisan otros fármacos como el propofol. El objetivo principal es revisar el uso de propofol en cuidados paliativos y describir varios pacientes que precisaron sedación paliativa con propofol en una Unidad de Cuidados Paliativos (UCP). MATERIAL Y MÉTODO: Estudio descriptivo retrospectivo. Se incluyeron, durante 10 meses, los pacientes que precisaron propofol por una sedación complicada y dos pacientes que fallecieron durante la inducción con propofol. Se registraron múltiples variables y comentarios de las historias clínicas para aclarar el motivo de precisar propofol. RESULTADOS: Existe poca literatura acerca del uso de propofol en cuidados paliativos, basada en casos clínicos aislados o series cortas de pacientes. Cuatro pacientes de nuestra revisión precisaron sedación con propofol. Estos casos fueron significativamente más jóvenes (55,5 años; p = 0,01) y la sedación fue más prolongada (7,5 días; p = 0,05). Los principales motivos para la sedación fueron sintomatología física múltiple o sufrimiento emocional. Todos los pacientes habían precisado dosis altas de otros fármacos sedantes y tuvieron mala respuesta a rescates de otros sedantes en las horas previas. Se propone una guía clínica para el uso de propofol en cuidados paliativos. CONCLUSIONES: - El propofol es un fármaco poco usado en cuidados paliativos, en general con buenos resultados. - Los pacientes que precisaron propofol por una sedación complicada fueron más jóvenes y tuvieron una sedación más prolongada. Destaca el intenso sufrimiento emocional. - Existen factores de sedación complicada o resistencia al midazolam que pueden ayudar a iniciar lo antes posible otro fármaco sedante más eficaz. - Se propone un protocolo para el uso de propofol en paliativos, recomendando comenzar con dosis bajas. - Es necesaria una mayor difusión en el empleo del propofol en una sedación complicada. - Son necesarios estudios que aclaren aspectos dudosos en el uso del propofol
BACKGROUND AND OBJECTIVES: The more patients cared for in palliative care, the more complicated situations arise - for example, palliative sedation due to a refractory symptom. Many factors may complicate a difficult sedation because of drug tolerance or interactions and psychological assessment. Resistance to usual sedative medications is frequent in these situations, and other pharmaceuticals like propofol, with limited use in a palliative care unit (PCU), are needed. The main objectives of this study were to research the available literature, and to report various PCU cases in a tertiary hospital where palliative sedation with propofol was needed. MATERIAL AND METHODS: A descriptive and retrospective study was performed during 10 months. Sedated patients with propofol were included. Also, two patients who died when induction doses of propofol were administered. Many variables were recorded. The clinical records of patients were also reviewed to elucidate the reason why propofol sedation was needed. RESULTS: Few studies exist examining the use of propofol in palliative care based on case reports or small series of cases. Four patients required sedation with propofol. These patients were younger (average age, 55.5, p = 0.01) and had a longer time between sedation onset and death (average time, 7.5 days, p = 0.05). The main symptoms motivating sedation were multifactorial and emotional suffering. All patients receiving propofol needed high-dose maintenance sedation with other sedative medications, and had responded minimally or not at all to rescue doses in previous hours. Updated guidelines for propofol use in PCUs have been drafted, with recommendations and dosages in case of complicated sedation. CONCLUSIONS: - Propofol use is limited in palliative care, usually with good results. Patients where propofol was needed were younger and sedation was longer. There was high emotional suffering in these patients. - There are factors responsible for complicated sedation or limited response to midazolam. Knowledge of these factors might help in providing earlier, more effective sedation. - Guidelines for propofol use in the PCU setting are proposed, recommending low maintenance doses initially. - A more widespread use of propofol as sedative medication in PCUs is recommended when complicated sedation occurs. - Further studies are needed to clarify many aspects of propofol use