Michael Jackson’s Trial

Michael Jackson

Now that the verdict is public with Michael Jackson’s trial, what does propofol really do?  This is a summary from The Medical Letter (October 2011) in response to a reader who asked for a review on the use of propofol

First marketed more than 20 years ago, propofol has a rapid onset of action (patients usually lose consciousness in less then one minute) and a short duration of action with a rapid recovery (3-5 minutes) that makes it highly suitable for brief ambulatory procedures.  This means any endoscopy for your colon may very well use propofol to sedate you for the procedure. 

Propofol use is not uncommon; in fact, it is the most widely used parenteral anesthetic in the US. 

 The main problems with its use have been pain on injection and bacterial contamination, both related to how its kept in solution.  The lipid emulsion formulation gives it the white, milky consistency. 

Milky color of propofol

Propofol has a narrow therapeutic window; this means there is a small difference between the “usual” dose and the toxic one.  Overdosing can readily induce states of deep sedation and general anesthesia, which could result in respiratory depression and loss of protective airway reflexes.  It appears this is what happened to MJ. 

 The following is a quote from The Medical Letter: “After years of use by emergency physicians and nurses, nurse anesthetists and gastroenterologists, among others, the Centers for Medicare and Medicaid Services (CMS) issued a memo in 2010 (soon after the propofol-related death of Michael Jackson) that has generally been interpreted as limiting the use of propofol for procedural sedation to anesthesiologists. This CMS guideline for Medicare and Medicaid patients has had a ripple effect on hospital emergency departments, where propofol has been widely used for intubation, and on endoscopy suites; patients who may have had endoscopies for years without receiving bills from anesthesiologists are receiving them now.

 The mortality rate associated with brief use of propofol is so low that few data are available comparing the safety of use by non-anesthesiologists with that of use by anesthesiologists.”

I like this list of references:  Most readers can pull articles of interest from PubMed–

1. Propofol. Med Lett Drugs Ther 1990; 32:22.

2. PM Patel et al in LL Brunton et al, eds, Goodman and Gilman’s The Pharmacological Basis of Therapeutics, 12th ed., New York: McGraw-Hill 2011, p. 536.

3. LB Cohen et al. A randomized, double-blind, phase 3 study of fospropofol disodium for sedation during colonoscopy. J Clin Gastroenterol 2010; 44:345.

4. TJ Gan et al. Safety evaluation of fospropofol for sedation during minor surgical procedures. J Clin Anesth 2010; 22:260.

5. DK Rex et al. Endoscopist-directed administration of propofol: a worldwide safety experience. Gastroenterology 2009;137:1229.

6. H Singh et al. Propofol for sedation during colonoscopy. Cochrane Database Syst Rev 2008; 4:CD006268.

For the full Medical Letter review, click on the link.

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