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