Propofol for Procedural Sedation
Short-acting intravenous hypnotic. Rapid onset and offset make propofol attractive for adult procedural sedation in the emergency department. It produces sedation/hypnosis but no reliable analgesia, depresses airway reflexes and respiratory drive, and causes vasodilatation and myocardial depression. There is no pharmacological reversal.
UK practice is governed by RCEM guidance and the RCEMLearning propofol module; NICE CG112 regards propofol in children as a specialist technique.
Pharmacology and pharmacokinetics
- Mechanism: positive allosteric modulation of GABAA receptors → CNS depression.
- Onset: within one arm-brain circulation (usually <1 minute) after IV bolus - rapidity permits fine titration but means effects appear quickly.
- Offset: single bolus effects commonly wane within ~10 minutes due to redistribution; repeated boluses or infusions accumulate and prolong recovery.
- Clinical variability: sensitivity and dose-response vary with age, frailty, cardiac output, volume status, chronic alcohol or benzodiazepine/opioid use, and co‑ingested sedatives or opioids.
- Reduced cardiac output delays onset; elderly, hypovolaemic or septic patients are more susceptible to hypotension.
Indications and scope
- Appropriate use: adult procedural sedation when rapid, titratable hypnosis and quick recovery are desired (e.g., cardioversion, short painful procedures where local anaesthesia is insufficient, some orthopaedic reductions).
- Only perform when local governance, staffing, monitoring and rescue capability meet RCEM standards.
- RCEMLearning provides operational protocols and training.