Introduction: Patients undergoing rapid sequence intubation (RSI) are at risk for inadequate postintubation sedation, a concern observed in prior studies and at a high-volume, urban, academic emergency department (ED) where subtherapeutic postintubation propofol dosing was noted. In response, the electronic health record (EHR) propofol order set was modified to increase the default starting dose. We aimed to determine whether postintubation sedation practices changed following this intervention. We hypothesized that both the initial propofol dose ordered and administered would increase. Methods: Prospective, observational, before-and-after study of adults undergoing RSI in an urban ED on weekdays between 8AM–12AM for 6 weeks in summer 2023 (pre-intervention) and 7 weeks in summer 2024 (post-intervention). In winter 2023, the EHR default propofol starting dose was increased from 5 to 15 mcg/kg/min. During study periods, trained researchers blinded to the hypothesis recorded propofol doses every 5 minutes for 2 hours post-RSI or until ED departure. Data were recorded in REDCap. Primary outcomes were changes in propofol starting dose ordered and administered post-intervention. Groups were compared using Chi-square or Fisher’s exact test for categorical variables and Wilcoxon rank sum for continuous variables. Summary statistics included number (percentage) and median IQR. Results: Of 49 patients intubated with RSI in the ED, 12 were excluded due to out of hospital or postintubation cardiac arrest, cricothyrotomy, or suspected opioid overdose, leaving 37 for analysis (19 pre- and 18 post-intervention). No demographic differences were noted: median age 64.0 years, 23 (62.2%) male, and 32 (86.5%) Black. 15 (78.9%) pre- and 17 (94.4%) of post-intervention patients received post-intubation propofol (p=0.34). Ordered propofol starting dose rose significantly from 5.0 5.0-15.0 to 15.0 15.0-15.0 mcg/kg/min (p=0.009). However, median administered dose did not differ: 20.0 12.5-25.0 pre- vs. 20.0 15.0-30.0 mcg/kg/min post-intervention (p=0.51). Conclusions: Increasing the EHR default propofol dose was associated with a significant rise in the propofol starting dose ordered, but not in the dose administered. Limitations include small sample size and single center design which limits generalizability.
Caputo et al. (Sun,) studied this question.