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Sharif S, Kang J, Sadeghirad B, Rizvi F, Forestell B, Greer A, Hewitt M, Fernando SM, Mehta S, Eltorki M, Siemieniuk R, Duffett M, Bhatt M, Burry L, Perry JJ, Petrosoniak A, Pandharipande P, Welsford M, Rochwerg B. Pharmacological agents for procedural sedation and analgesia in the emergency department and intensive care unit: a systematic review and network meta-analysis of randomised trials. Br J Anaesth 2024; 132:491-506. [PMID: 38185564 DOI: 10.1016/j.bja.2023.11.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/29/2023] [Accepted: 11/30/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND We aimed to evaluate the comparative effectiveness and safety of various i.v. pharmacologic agents used for procedural sedation and analgesia (PSA) in the emergency department (ED) and ICU. We performed a systematic review and network meta-analysis to enable direct and indirect comparisons between available medications. METHODS We searched Medline, EMBASE, Cochrane, and PubMed from inception to 2 March 2023 for RCTs comparing two or more procedural sedation and analgesia medications in all patients (adults and children >30 days of age) requiring emergent procedures in the ED or ICU. We focused on the outcomes of sedation recovery time, patient satisfaction, and adverse events (AEs). We performed frequentist random-effects model network meta-analysis and used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to rate certainty in estimates. RESULTS We included 82 RCTs (8105 patients, 78 conducted in the ED and four in the ICU) of which 52 studies included adults, 23 included children, and seven included both. Compared with midazolam-opioids, recovery time was shorter with propofol (mean difference 16.3 min, 95% confidence interval [CI] 8.4-24.3 fewer minutes; high certainty), and patient satisfaction was better with ketamine-propofol (mean difference 1.5 points, 95% CI 0.3-2.6 points, high certainty). Regarding AEs, compared with midazolam-opioids, respiratory AEs were less frequent with ketamine (relative risk [RR] 0.55, 95% CI 0.32-0.96; high certainty), gastrointestinal AEs were more common with ketamine-midazolam (RR 3.08, 95% CI 1.15-8.27; high certainty), and neurological AEs were more common with ketamine-propofol (RR 3.68, 95% CI 1.08-12.53; high certainty). CONCLUSION When considering procedural sedation and analgesia in the ED and ICU, compared with midazolam-opioids, sedation recovery time is shorter with propofol, patient satisfaction is better with ketamine-propofol, and respiratory adverse events are less common with ketamine.
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Affiliation(s)
- Sameer Sharif
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada; Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
| | - Jasmine Kang
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Fayyaz Rizvi
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ben Forestell
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Alisha Greer
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada; Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Mark Hewitt
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada; Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Shannon M Fernando
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada; Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health System; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Mohamed Eltorki
- Department of Pediatrics, Division of Pediatric Emergency Medicine, McMaster University, Ottawa, ON, Canada
| | - Reed Siemieniuk
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Mark Duffett
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Maala Bhatt
- Department of Medicine, Sinai Health System, Interdepartmental Division of Critical Care Medicine, Toronto, ON, Canada
| | - Lisa Burry
- Department of Medicine, Sinai Health System; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Pharmacy, Sinai Health System, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Andrew Petrosoniak
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada
| | - Pratik Pandharipande
- Department of Anesthesiology, Division of Critical Care, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Michelle Welsford
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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Abstract
Supplemental Digital Content is available in the text.
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Vahidi E, Hemati R, Momeni M, Jahanshir A, Saeedi M. Comparison of sedative effectiveness of thiopental versus midazolam in reduction of shoulder dislocation. World J Emerg Med 2018; 9:125-129. [PMID: 29576825 PMCID: PMC5847498 DOI: 10.5847/wjem.j.1920-8642.2018.02.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Accepted: 01/08/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Various sedative drugs have been proposed to control anxiety and agitation in shoulder dislocation, but none of them has been diagnosed as the best sedative and relaxant agent. The study aimed to compare the sedative effectiveness of thiopental versus midazolam in reduction of shoulder dislocation. METHODS A randomized double-blind controlled trail was performed in 80 patients with shoulder dislocation recruited from the emergency department. Ten patients were excluded and 70 patients were enrolled in the study. Case group received intravenous thiopental 2 mg/kg+2 µg/kg fentanyl while control group received intravenous midazolam 0.1 mg/kg+2 µg/kg fentanyl. Number of times, patients and physician's satisfaction, difficulty of procedure, degree of muscle relaxation, time of sedation and complete recovery, number of patients with apnea episode, O2 saturation, patient's pain score and adverse events were all recorded. RESULTS Muscular tone had significant difference between the two groups (P-value=0.014) and thiopental was more muscle relaxant than midazolam. Replacement of shoulder dislocation in thiopental group was easier than midazolam group (P-value=0.043). There was no need to use multiple methods of reduction in either group. Before drug infusion the mean±SD VAS scores were 8.37±2.21 in the midazolam group (A) and 8.94±1.78 in the thiopental group (B); mean difference 0.57, 95% CI= -0.38 to 1.52. After completion of the procedure, the mean±SD VAS scores in group (A) and (B) were 3.20±1.30 vs. 3.65±1.30; mean difference -0.45, 95% CI= -1.07 to 0.16. CONCLUSION Thiopental might be more effective and relaxant than midazolam for reduction of shoulder dislocation.
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Affiliation(s)
- Elnaz Vahidi
- Emergency Medicine Research Center, Shariati Hospital, Emergency Medicine Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Rezvan Hemati
- Emergency Medicine Research Center, Shariati Hospital, Emergency Medicine Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Momeni
- Emergency Medicine Research Center, Shariati Hospital, Emergency Medicine Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirhossein Jahanshir
- Emergency Medicine Research Center, Shariati Hospital, Emergency Medicine Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Morteza Saeedi
- Emergency Medicine Research Center, Shariati Hospital, Emergency Medicine Department, Tehran University of Medical Sciences, Tehran, Iran
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Chan KKL, Ho HF. Etomidate and Midazolam for Procedural Sedation in the Emergency Department of Queen Elizabeth Hospital: A Randomised Controlled Trial. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790801500203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective The objective of the study was to compare the effectiveness and safety of intravenous etomidate against midazolam in procedures which required sedation and analgesia in our emergency department. Methods The study was conducted in the emergency department of Queen Elizabeth Hospital from 1st November 2005 to 30th June 2006. Adult patients who required procedural sedation and analgesia were recruited and randomised into two groups, in which either etomidate or midazolam was used as the sedative agent. Vital parameters and depth of sedation were closely monitored until they regained full consciousness. Results a total of 87 patients were recruited and randomised into study and control groups, of which 78 patients completed the study and were analysed – 36 patients were in the midazolam group whereas 42 patients were in the etomidate group. There was no statistical difference in mean age, mean weight and procedures between the two groups. Mean time for onset of action was 1.8 minutes for the etomidate group versus 3.4 minutes for the midazolam group (p=0.003). There were no significant differences in total procedure time, total length of stay, pain score, satisfaction score and adverse effects. Conclusion Etomidate achieved adequate depth of sedation for painful procedures in significantly shorter time than midazolam. There were no differences in procedure time, length of stay, pain relief and patient's satisfaction between the two drugs.
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Comparison of ketamine/propofol (ketofol) and etomidate/fentanyl (etofen) combinations for procedural sedation and analgesia in the emergency department: An observational study. Turk J Emerg Med 2017; 17:89-94. [PMID: 28971155 PMCID: PMC5608606 DOI: 10.1016/j.tjem.2017.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 01/05/2017] [Accepted: 01/23/2017] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES The primary aim of this study was to report the vital signs, hemodynamic parameters and pain scores of the patients who have received procedural sedation and analgesia (PSA) with either ketofol (combination of ketamine and propofol) or etofen (combination of etomidate and fentanyl) and compare the proportion of patients with airway or respiratory adverse events (AEs) requiring an intervention and calculate the relative risk of AEs with each combination. METHODS This study is a prospective observational study with survey analysis. All patients received procedural sedation and analgesia (PSA) with either ketofol (combination of ketamine and propofol) or etofen (combination of etomidate and fentanyl) were prospectively observed. Vital and hemodynamic parameters and pain scores of the patients were recorded by automated equipment and visual analog scale (VAS) charts. RESULTS 112 patients were enrolled, 55 received ketofol and 57 received etofen. All patients with a respiratory AE (n = 27) observed to receive a respiratory intervention. Respiratory AE rate and proportion of patient who required a respiratory intervention were significantly higher with ketofol (p = 0.0029). Overall AE rate, and rates of desaturation, emergence reaction were also significantly higher in ketofol group. CONCLUSION Etofen is a promising combination for the PSA of adult patients with lower respiratory AE and intervention rates and with better hemodynamic profile.
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Abstract
Procedural sedation options in the emergency department now allow for more effective and safer care and facilitate the delivery of orthopaedic care that would otherwise require operating room anesthesia. Traditional sedation agents, such as nitrous oxide, midazolam, fentanyl, and ketamine, have a persistent role. Etomidate and propofol are relatively recent additions that are highly effective. Combination regimens, such as ketamine-midazolam and ketamine-propofol, may be superior because they benefit from synergistic traits. Despite these sedation regimens, use of local blocks in adults continues to be effective, and intranasal delivery in children has emerged as a viable option. Orthopaedic surgeons should be aware of the appropriateness of different sedation regimens and other options for specific clinical scenarios.
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Shen XC, Ao X, Cao Y, Lan L, Liu XM, Sun WJ, Li P, Lan CH. Etomidate-remifentanil is more suitable for monitored anesthesia care during gastroscopy in older patients than propofol-remifentanil. Med Sci Monit 2015; 21:1-8. [PMID: 25553506 PMCID: PMC4288392 DOI: 10.12659/msm.891183] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background This prospective and randomized study was designed to compare safety, potential complications, and patient and examiner satisfaction of 2 anesthetic combinations – etomidate-remifentanil and propofol-remifentanil – in elderly patients undergoing diagnostic gastroscopy. Material/Methods A group of 720 patients, aged 60–80 years, scheduled for diagnostic gastroscopy under sedation were prospectively randomized. After 0.4–0.6 μg kg−1 of remifentanil was infused, etomidate or propofol was administered. Patients in the etomidate group received doses of etomidate at 0.1–0.15 mg kg−1 followed by 4–6 mg. Patients in the propofol group received doses of propofol at 1–2 mg kg−1 followed by 20–40 mg. Physiological indexes were evaluated for the 715 of 720 patients that completed the treatment. The onset time, duration time, and discharge time were recorded. Physicians, anesthetists, and patients were surveyed to assess their satisfaction. Results Systolic pressure and diastolic pressure decreased significantly after the procedure in the propofol group (P<0.001). The average heart rate was significantly lower in the propofol group (P<0.05). No periods of desaturation (SpO2 <95%) were observed in either group. The onset time was earlier in the etomidate group (P=0.00). All adverse events, with the exception of myoclonus, were greater in the propofol group, and physician and patient satisfaction in both groups was similar. Conclusions Etomidate-remifentanil administration for sedation and analgesia during gastroscopy resulted in more stable hemodynamic responses and less adverse events in older patients.
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Affiliation(s)
- Xiao-Chun Shen
- Department of Gastroenterology, Daping Hospital, Third Military Medical University, Chongqing, China (mainland)
| | - Xing Ao
- Department of Gastroenterology, Daping Hospital, Third Military Medical University, Chongqing, China (mainland)
| | - Yan Cao
- Department of Gastroenterology, Daping Hospital, Third Military Medical University, Chongqing, China (mainland)
| | - Li Lan
- Department of Gastroenterology, Daping Hospital, Third Military Medical University, Chongqing, China (mainland)
| | - Xin-Man Liu
- Department of Gastroenterology, Daping Hospital, Third Military Medical University, Chongqing, China (mainland)
| | - Wen-Jing Sun
- Department of Gastroenterology, Daping Hospital, Third Military Medical University, Chongqing, China (mainland)
| | - Ping Li
- Department of Gastroenterology, Daping Hospital, Third Military Medical University, Chongqing, China (mainland)
| | - Chun-Hui Lan
- Department of Gastroenterology, Daping Hospital, Third Military Medical University, Chongqing, China (mainland)
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ERDOES G, BASCIANI RM, EBERLE B. Etomidate--a review of robust evidence for its use in various clinical scenarios. Acta Anaesthesiol Scand 2014; 58:380-9. [PMID: 24588359 DOI: 10.1111/aas.12289] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2014] [Indexed: 02/02/2023]
Abstract
Etomidate is an intravenous hypnotic with a favourable clinical profile in haemodynamic high-risk scenarios. Currently, there is an active debate about the clinical significance of the drug's side effects and its overall risk-benefit ratio. Etomidate-induced transient adrenocortical suppression is well documented and has been associated with increased mortality in sepsis. In surgical patients at risk of hypotensive complications, however, a review of current literature provides no robust evidence to contraindicate a single-bolus etomidate induction. Large randomised controlled trials as well as additional observational data are required to compare safety of etomidate and its alternatives.
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Affiliation(s)
- G. ERDOES
- Department of Anaesthesiology and PainTherapy; University Hospital Bern; Bern Switzerland
| | - R. M. BASCIANI
- Department of Anaesthesiology and PainTherapy; University Hospital Bern; Bern Switzerland
| | - B. EBERLE
- Department of Anaesthesiology and PainTherapy; University Hospital Bern; Bern Switzerland
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Denny MA, Manson R, Della-Giustina D. Propofol and Etomidate are Safe for Deep Sedation in the Emergency Department. West J Emerg Med 2012; 12:399-403. [PMID: 22224127 PMCID: PMC3236171 DOI: 10.5811/westjem.2011.5.2099] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Revised: 12/23/2010] [Accepted: 05/02/2011] [Indexed: 11/11/2022] Open
Abstract
This study describes deep sedations performed for painful procedures completed in the emergency department at an academic tertiary care hospital during an 18-month period. One hundred consecutive cases were retrospectively reviewed to describe indications, complications, procedural lengths, medication dosing, and safety of these sedations. Propofol and etomidate were the preferred agents. We found that there were relatively few complications (10%), with only 2 of these (2%) being major complications. All complications were brief and did not adversely affect patient outcomes. This data further demonstrate the safety profile of deep sedation medications in the hands of emergency physicians trained in sedation and advanced airway techniques.
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Affiliation(s)
- Mark A Denny
- Diley Ridge Medical Center, Canal Winchester, Ohio
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Comparison of the Effects of Etomidate and Propofol Combined With Remifentanil and Guided By Comparable BIS on Transcranial Electrical Motor-evoked Potentials During Spinal Surgery. J Neurosurg Anesthesiol 2012; 24:133-8. [DOI: 10.1097/ana.0b013e31823dfb2e] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Comparison of etomidate–remifentanil and propofol–remifentanil sedation in patients scheduled for colonoscopy. Eur J Anaesthesiol 2009; 26:370-6. [DOI: 10.1097/eja.0b013e328318c666] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Nestor NB, Burton JH. ED use of etomidate for rapid sequence induction. Am J Emerg Med 2008; 26:946-50. [DOI: 10.1016/j.ajem.2007.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2007] [Revised: 12/04/2007] [Accepted: 12/05/2007] [Indexed: 11/15/2022] Open
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Fitch RW, Kuhn JE. Intraarticular lidocaine versus intravenous procedural sedation with narcotics and benzodiazepines for reduction of the dislocated shoulder: a systematic review. Acad Emerg Med 2008; 15:703-8. [PMID: 18783486 DOI: 10.1111/j.1553-2712.2008.00164.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Anterior shoulder dislocations commonly present to the emergency department (ED). The time associated with procedural sedation for the reduction of anterior shoulder dislocations can be lengthy and may require use of additional personnel. Complications associated with intravenous (IV) medications for procedural sedation are well documented. OBJECTIVES The aim was to determine if intraarticular lidocaine (IAL) injection is as effective as IV procedural sedation with narcotics and benzodiazepines for reduction of anterior shoulder dislocations. METHODS This was a systematic review of randomized controlled trials (RCTs). The authors performed a PubMed, EMBASE, and Cochrane database search using key words: "shoulder dislocation" and "reduction" and retrieved every RCT published that compared the use of IV sedation to IAL as medication for reduction. Each manuscript was reviewed and the results of each was compared regarding medications used, success of reduction, complications, pain perceived, ease of reduction, and time spent in the ED. RESULTS Six Level 1 RCTs were identified. No studies showed a statistically significant difference in success rate between IAL versus IV sedation. The complication rate was significantly higher in the IV sedation groups (p < 0.001), and the total time spent in the ED was longer for the IV sedation group. CONCLUSIONS The use of IAL for reduction of anterior shoulder dislocations should be strongly considered as a first line therapy because it is effective and safe and may potentially reduce time spent in the ED.
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Heid F, Gerth M, Roth W, Hessmann M, Werner C. [Procedural analgesia : concepts and practice]. Chirurg 2008; 79:738-44. [PMID: 18347762 DOI: 10.1007/s00104-008-1507-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The effect of severe pain and its hazardous stress-related cardiocirculatory consequences have been well documented for the perisurgical setting. Independently of surgical intervention however, even short and simple measures (e.g. thorax drain removal, repositioning a limb fracture) and longer diagnostic procedures such as MRI are potentially very painful or stressful to the patient. Though longer diagnostic procedures are frequently supported by systemic medication, short interventions regularly lack this aspect. Specific challenges result from the need to counteract sometimes great changes in pain intensity. Moreover procedural analgesia represents a multidisciplinary measure not restricted to anaesthesiology, as most of these measures are performed without anaesthesia. To avoid endangering the patient, the choice of drugs and patient monitoring have to meet certain professional and technical standards. Competence in respiratory management is of paramount importance. This paper outlines these requirements and serves as an orientation outside the anaesthesiological speciality.
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Affiliation(s)
- F Heid
- Klinik für Anästhesiologie, Johannes Gutenberg-Universität, Langenbeckstrasse 1, 55131, Mainz, Deutschland.
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Davidson JE, Bloomberg D, Burnell L. Scope creep: when nursing practice moves beyond traditional boundaries: an evidence-based example using procedural sedation. Crit Care Nurs Q 2007; 30:219-32. [PMID: 17579305 DOI: 10.1097/01.cnq.0000278922.21821.52] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The finite boundaries of the scope of nursing practice are constantly changing. One could expect that with new technology and advances in science, the interventions and assessments nurses perform will change over time. The practice of nursing is governed by nursing, however, it is often challenged by our partners in medicine, and frequently driven by time constraints or reimbursement issues. This article reviews a case example in which nurses were asked to expand their practice to assume responsibility for duties that were once traditionally performed by physicians. An evaluation of a practice problem using an evidence-based approach applying the PICO (population, intervention, comparison, outcome) method is explored. Proposed steps to minimize risk and staff moral distress are also described.
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MESH Headings
- Academic Medical Centers
- Attitude of Health Personnel
- California
- Certification
- Clinical Competence
- Conscious Sedation/nursing
- Critical Care
- Delegation, Professional
- Education, Nursing, Continuing/organization & administration
- Emergency Service, Hospital
- Evidence-Based Medicine/organization & administration
- Humans
- Liability, Legal
- Nurse's Role
- Nursing Evaluation Research/organization & administration
- Nursing Staff, Hospital/education
- Nursing Staff, Hospital/organization & administration
- Nursing Staff, Hospital/psychology
- Organizational Policy
- Outcome Assessment, Health Care
- Professional Autonomy
- Safety Management
- Societies, Medical/organization & administration
- Societies, Nursing/organization & administration
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Lucas da Silva PS, Oliveira Iglesias SB, Leão FVF, Aguiar VE, Brunow de Carvalho W. Procedural sedation for insertion of central venous catheters in children: comparison of midazolam/fentanyl with midazolam/ketamine. Paediatr Anaesth 2007; 17:358-63. [PMID: 17359405 DOI: 10.1111/j.1460-9592.2006.02099.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND There is a lack of studies evaluating procedural sedation for insertion of central venous catheters (CVC) in pediatric patients in emergency departments or pediatric intensive care units (PICU). This study was designed to evaluate whether there is a difference in the total sedation time for CVC insertion in nonintubated children receiving two sedation regimens. METHODS Patients were prospectively randomized to receive either midazolam/fentanyl (M/F) or midazolam/ketamine (M/K) i.v. The Children's Hospital of Wiscosin Sedation Scale was used to score the sedation level. RESULTS Fifty seven patients were studied (28 M/F and 29 M/K). Group M/F received midazolam (0.24 +/- 0.11 mg.kg(-1)) and fentanyl (1.68 +/- 0.83 microg.kg(-1)) and group M/K received midazolam (0.26 +/- 0.09 mg.kg(-1)) and ketamine (1.40 +/- 0.72 mg.kg(-1)). The groups were similar in age, weight, risk classification time and sedation level. Median total sedation times for M/F and M/K were 97 vs 105 min, respectively (P = 0.67). Minor complications occurred in 3.5% (M/F) vs 20.7% (M/K) (P = 0.03). M/F promoted a greater reduction in respiratory rate (P = 0.005). CONCLUSIONS In this study of nonventilated children in PICU undergoing central line placement, M/F and M/K provided a clinically comparable total sedation time. However, the M/K sedation regimen was associated with a higher rate of minor complications. A longer period of study is required to assess the efficacy and safety of these sedative agents for PICU procedures in nonintubated children.
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Affiliation(s)
- Paulo Sérgio Lucas da Silva
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital do Servidor Público Municipal de São Paulo, São Paulo, Brazil.
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Deitch K, Chudnofsky CR, Dominici P. The Utility of Supplemental Oxygen During Emergency Department Procedural Sedation and Analgesia With Midazolam and Fentanyl: A Randomized, Controlled Trial. Ann Emerg Med 2007; 49:1-8. [PMID: 16978741 DOI: 10.1016/j.annemergmed.2006.06.013] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2005] [Revised: 05/26/2006] [Accepted: 06/12/2006] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVE To determine whether supplemental oxygen reduces the incidence of hypoxia by 20% in study patients receiving midazolam and fentanyl for emergency department procedural sedation and analgesia. METHODS Patients were randomized to receive either supplemental oxygen or compressed air by nasal cannula at 2 L per minute. Physicians were blinded to the gas used and end-tidal carbon dioxide (ETCO2) data. Respiratory depression was defined a priori as oxygen saturation less than 90%, ETCO2 level greater than 50 mm Hg, an absolute change from baseline of 10 mm Hg, or loss of the ETCO2 waveform. RESULTS Of the 80 patients analyzed, 44 received supplemental oxygen and 36 received compressed air. Twenty supplemental oxygen patients and 19 compressed air patients met at least 1 criterion for respiratory depression. Six supplemental oxygen patients and 5 compressed air patients experienced hypoxia (P=.97; effect size 0%; 95% confidence interval -15% to +15%). Fourteen patients in each group met ETCO2 criteria for respiratory depression but were not hypoxic. Physicians identified respiratory depression in 8 of 11 patients who became hypoxic and 0 of 28 patients who met ETCO2 criteria for respiratory depression but who did not become hypoxic. There were no adverse events. CONCLUSION Supplemental oxygen did not reduce (or trend toward reducing) the incidence of hypoxia in patients moderately sedated with midazolam and fentanyl. However, our lower-than-expected rate of hypoxia limits the power of this comparison. Blinded capnography frequently identified respiratory depression undetected by the treating physicians.
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Affiliation(s)
- Kenneth Deitch
- Department of Emergency Medicine, Albert Einstein Medical Center, Philadelphia, PA 19141, USA.
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Green SM. Research Advances in Procedural Sedation and Analgesia. Ann Emerg Med 2007; 49:31-6. [PMID: 17083997 DOI: 10.1016/j.annemergmed.2006.09.020] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2006] [Revised: 09/11/2006] [Accepted: 09/20/2006] [Indexed: 11/18/2022]
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Perrone J, Band RA, Mathew R. Agitation complicating procedural sedation with etomidate. Am J Emerg Med 2006; 24:511-2. [PMID: 16787821 DOI: 10.1016/j.ajem.2006.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2006] [Accepted: 04/01/2006] [Indexed: 11/29/2022] Open
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