Although none of the editors of InsideSurgery.com participated in his care, we have followed closely the news reports of his death and the developing story that physician-prescribed sedatives might have contributed to an overdose that caused a cardiorespiratory death.
Major news organizations are now reporting that the coroner is likely to rule Jackson’s death a homicide. The reported exact doses and schedule of the powerful sedatives prescribed to Jackson are being detailed.
The author of this post is a critical care physician who has wide experience with administering Valium, Ativan, and propofol to patients and who has received propofol as a patient. Some thoughts on the use of these drugs and the care that Jackson reportedly received is below:
First and foremost, propofol (Diprivan) should never be given in a home setting: this is grossly outside of the scope of acceptable practice. This drug is a cardiac and respiratory depressant and should only be given by anesthesia and intensive care physicians with wide experience.
Propofol has a relatively short onset of duration and a short duration of effect – if the patient is drug naieve to it. That is, if you only see the drug when you have your colonscopy every five years, it works within seconds of onset and “goes away when it is turned off.”
However, it can and will build up in the tissues in patients who have received long infusions of it or shorter, frequent exposure to it and can potentiate additional doses.
Jackson’s doctor reportedly said that he injected Jackson and then left the room for a few minutes and when he returned, Jackson had stopped breathing. Patients should NEVER be left alone after being administered propofol, even for a few seconds.
Patients being given this drug must be placed on a heart monitor that detects heart rate and a blood pressure monitor of some type. It is not clear from reports if this was done by Dr. Murray
Jackson’s doctor claims he placed an oxygen saturation monitor on the patient. This device is a measure of oxygenation or “O2 saturation” only.
This type of monitor does not measure the respiratory status of a patient or how deeply and how fast a patient is breathing. It does not measure the patients partial pressure of carbon dioxide or PCO2, which is the important respiratory fvalue to monitor when giving propofol and “benzo’s”.
For example, it is possible to be dead and have a normal oxygen saturation for several minutes.
A physician who does not understand the above described limitations of monitoring is by definition not qualified to administer the drug.
When giving propofol to a non-intubated patient (i.e., without the breathing tube), the maximum initial dose I will use is 10 mgs. Dr. Murray administered 25 mgs after several doses of benzodiazepines (Ativan, Valium, and Versed), which will increase the heart and lung depression effect of propofol.
Patients sedated with propofol are not asleep (as Michael Jackson wished to be) and the use of propofol as a sleep inducer in the United States is outside the scope of standard care.
There is no reversal drug or antidote available to treat a propofol overdose, unlike Ativan, Valium, and Versed (which can be treated with the drug flumazenil.)
Patients who have respiratory depression with propofol need artificially controlled respirations by one of several methods.
A bag mask can be placed over the mouth and nose with air or oxygen forced into the lungs by squeezing it. Alternately, an endotracheal tube (breathing tube) or laryneal mask airway can be placed into the pharynx with air or oxygen delivered to the lungs.
It is not clear from reports if Dr. Murray had these items available when he administered the propofol, but if he did not it would be grossly negligent.
Benzodiazepines (Valium, Ativan, Versed)
Unlike propofol, these drugs are used as sleep inducers, but they are also strong sedatives that have the same respiratory and cardiac depressant effects as propofol.
Reports claim that Jackson was injected with these drugs. It is not clear if the injection was into a vein (intravenously) or into the muscle (intramuscularly or IM.)
Almost universally in the United States, benzodiazepines administered at home are given orally in pill form.
After Jackson was found to be in arrest, it is not clear if he was given flumazenil to reverse the effect of the Valium, Ativan, or Versed or if this was even available.
In medical settings, this reversal drug is typically available in case of overdose.
The dose and timing of the benzo’s given to Jackson is not inordinately high for an intensive care setting for a patient on a ventilator, but it is more than would be considered prudent in an outpatient, home setting.
Criminal Charges/Medical Malpractice
If accurate as reported, the administration of these drugs in this manner to Michael Jackson by Dr. Murray is widely deviant from standard of care. It may even be criminally negligent. However, although I am not an attorney or judge, it seems difficult to see how this would fit the charge of murder. It seems unlikely that Murray was intentionally giving Jackson these drugs to harm him.