The FDA has approved remimazolam (Byfavo – Acacia Pharma), an ultra-short-acting IV benzodiazepine, for induction and maintenance of sedation in adults undergoing procedures of up to 30 minutes' duration.

A reader has asked us to review the use of propofol (Diprivan, and others) as a sedative agent for brief procedures, such as colonoscopy.

First marketed more than 20 years ago,1 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. Propofol is now the most commonly used parenteral anesthetic in the US.2 The main problems with its use have been pain on injection and bacterial contamination, both related to its lipid emulsion formulation; fospropofol (Lusedra) is a water-soluble prodrug of propofol that acts similarly without pain on IV injection or a significant potential for contamination.3,4 Both propofol and fospropofol have a narrow therapeutic window; overdosing can readily induce states of deep sedation and general anesthesia, which could result in respiratory depression and loss of protective airway reflexes.

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.5,6

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.

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Opioids, benzodiazepines, propofol, antipsychotics and dexmedetomidine (Precedex) are frequently used in the intensive care unit (ICU) to manage pain, anxiety, agitation and delirium, and to facilitate procedures such as mechanical ventilation. The use of dexmedetomidine, a centrally-acting selective α₂-receptor agonist approved by the FDA in 1999, has been increasing in recent years. Some new studies comparing it to other drugs for ICU sedation have been published.