Clinical policy: Procedural sedation and analgesia in the emergency department

Sleep loss, caffeine, sleep aids and sedation modify brain abnormalities of mild traumatic brain injury

Little evidence exists about how mild traumatic brain injury (mTBI) is affected by commonly encountered exposures of sleep loss, sleep aids, and caffeine that might be potential therapeutic opportunities. In addition, while propofol sedation is administered in severe TBI, its potential utility in mild TBI is unclear. Each of these exposures is known to have pronounced effects on cerebral metabolism and blood flow and neurochemistry. We hypothesized that they each interact with cerebral metabolic dynamics post-injury and change the subclinical characteristics of mTBI. MTBI in rats was produced by head rotational acceleration injury that mimics the biomechanics of human mTBI. Three mTBIs spaced 48 h apart were used to increase the likelihood that vulnerabilities induced by repeated mTBI would be manifested without clinically relevant structural damage. After the third mTBI, rats were immediately sleep deprived or administered caffeine or suvorexant (an orexin antagonist and sleep aid) for the next 24 h or administered propofol for 5 h. Resting state functional magnetic resonance imaging (rs-fMRI) and diffusion tensor imaging (DTI) were performed 24 h after the third mTBI and again after 30 days to determine changes to the brain mTBI phenotype. Multi-modal analyses on brain regions of interest included measures of functional connectivity and regional homogeneity from rs-fMRI, and mean diffusivity (MD) and fractional anisotropy (FA) from DTI. Each intervention changed the mTBI profile of subclinical effects that presumably underlie healing, compensation, damage, and plasticity. Sleep loss during the acute post-injury period resulted in dramatic changes to functional connectivity. Caffeine, propofol sedation and suvorexant were especially noteworthy for differential effects on microstructure in gray and white matter regions after mTBI. The present results indicate that commonplace exposures and short-term sedation alter the subclinical manifestations of repeated mTBI and therefore likely play roles in symptomatology and vulnerability to damage by repeated mTBI.

Efficact of Supplemental Oxygen During Procedural Sedation and Analgesia in Elderly Patients in the Emergency Department

BACKGROUND

The use of supplemental oxygen (SO) for procedural sedation and analgesia (PSA) is recommended in many guidelines, but the evidence of SO for the elderly is limited.

OBJECTIVES

This study aimed to compare the incidence of hypoxia with or without SO in PSA for the elderly patients.

METHODS

We prospectively collected data on all patients undergoing PSA in the emergency department (ED) from May 2017 through December 2021. These data are from the Japanese Procedural SedaTion and Analgesia Registry. We included all elderly patients (65 years and older) who received PSA in the ED. We performed propensity score analysis for inverse probability of treatment weighting (IPTW) to balance the baseline characteristics. The primary outcome was the incidence of hypoxia (SpO2 < 90%), and the secondary outcome was the incidence of bag-valve mask ventilation.

RESULTS

Among 1465 patients in the registry, we included 816 (55.7%) patients in the analysis. After propensity score method for IPTW, the distributions of confounders were closely balanced between the two groups. The incidence of hypoxia was significantly lower in the SO group compared with the non-SO group (6.2% vs. 19.3%; difference -13.1%; 95% confidence interval [CI] -9.8 to -16.4; p < 0.001). SO was also associated with a lower incidence of bag-valve mask ventilation (5.2% vs. 15.4%; difference -10.2%; 95% CI -7.1 to -13.2; p < 0.001).

CONCLUSIONS

In a propensity-matched analysis, SO was associated with a lower incidence of hypoxia in elderly patients during ED PSA.

Requirement for Discharge in the Care of a Responsible Adult in Procedural Sedation in the Emergency Department: Necessity or Potential Barrier to Health Equity?

BACKGROUND

Procedural sedation is commonly practiced by emergency physicians to facilitate patient care in the emergency department (ED). Although various guidelines have modernized our approach to procedural sedation, many procedural sedation guidelines and practices still often require that patients be discharged into the care of a responsible adult.

DISCUSSION

Such requirement for discharge often cannot be met by underserved and undomiciled patients. Benzodiazepines, opioids, propofol, ketamine, "ketofol," etomidate, and methohexital have all been utilized for procedural sedation in the ED. For patients who may require discharge without the presence of an accompanying responsible adult, ketamine, propofol, methohexital, "ketofol," and etomidate are ideal agents for procedural sedation given rapid onsets, short durations of action, and rapid recovery times in patients without renal or hepatic impairment. Proper pre- and postprocedure protocols should be utilized when performing procedural sedation to ensure patient safety. Through the use of appropriate medications and observation protocols, patients can safely be discharged 2 to 4 h postprocedure.

CONCLUSION

There is no pharmacodynamic or pharmacokinetic basis to require discharge in the care of a responsible adult after procedural sedation. Thoughtful medication selection and the use of evidence-based pre- and postprocedure protocols in the ED can help circumvent this requirement, which likely disproportionally impacts patients who are of low socioeconomic status or undomiciled.

Procedural sedation analgesia in the elderly patient

Elderly patients are perceived as a high-risk group for procedural sedation. Procedural sedation analgesia (PSA) is generally safe in older adults. What is not acceptable is undertreating pain or inadequately sedating a stable patient. All the usual precautions should be taken. One should consider any comorbidities that could make the patient more at risk of adverse reactions or complications. Older patients may be at higher risk for oxygen desaturation, but they usually respond quickly to supplemental oxygen. Geriatric patients usually require lower doses of medications. They tend to be more sensitive to medications, with slower metabolism, less physiologic reserve to handle side effects, and a smaller volume of distribution. The use of drugs for sedation in elderly patients requires careful consideration of their age-related changes in physiology and pharmacokinetics. The choice of drug should be based on the patient's medical condition, comorbidities, and potential adverse effects. Moreover, the administration should be done by trained personnel with close monitoring of vital signs and level of consciousness to prevent complications such as respiratory depression.

The radiographic quality of conservatively managed distal radius fractures in adults using haematoma block versus intravenous sedation

OBJECTIVE

We compared the radiographic quality of initial reduction of distal radius fractures reduced using haematoma block to those reduced with intravenous sedation. The overall rate of re-manipulation and complications were noted.

METHODS

A prospective study carried out at the emergency unit of our hospital between 1st September, 2017 and 31st December, 2018. Patients were consecutively recruited into Haematoma Block (HB) and Sedation(S) groups using the simple balloting method. After 5-10 min of administering anaesthesia, the fracture was reduced and immobilized in a below-to-elbow Plaster of Paris (P.O.P) cast for 6 weeks. The pre- and post-reduction radiographs were reviewed for volar tilt, radial angulation, radial deviation and radial shortening.

RESULTS

Sixty-seven patients completed the study with 33 patients in HB group and 34 patients in S group. There was no significant difference in the radiographic quality of initial reduction between the two groups using the Sarmiento's modification of Lindström criteria (p = 0.49). Five out of 34 patients among the sedated group had gastrointestinal symptoms. The overall rate of re-manipulation was low and the complications recorded were wrist stiffness and residual wrist deformity.

CONCLUSION

Our study revealed that there was no significant difference in the radiographic quality of initial reduction between the groups. Excellent to good reduction was achieved with both anaesthetic options. The choice of anaesthesia should be individualized and based on surgeons' preference.

Circumferential periosteal block versus hematoma block for the reduction of distal radius and ulna fractures: a randomized controlled trial

PURPOSE

To assess the analgesic efficacy of the circumferential periosteal block (CPB) and compare it with the conventional fracture hematoma block (HB).

METHODS

This study was a prospective single-center randomized controlled trial performed in a national orthopedic hospital. Fifty patients with displaced distal radius (with or without concomitant ulna) fractures requiring reduction were randomized to receive either CPB or HB prior to the reduction. Pain was sequentially measured using the visual analogue scale (VAS) across three stages; before administration of local anesthesia (baseline), during administration (injection) and during manipulation and immobilization (manipulation). Further, the effect of demographic factors on the severity of pain was analyzed in multivariate regression. Finally, complications and end outcomes were compared across both techniques.

RESULTS

Patients receiving CPB experienced significantly less pain scores during manipulation (VAS = 0.64) compared with HB (VAS = 2.44) (p =  < 0.0001). There were no significant differences between groups at baseline (P = 0.55) and injection (P = 0.40) stages.

CONCLUSION

The CPB provides a superior analgesic effect over the conventional HB with no documented complications in either technique.

LEVEL OF EVIDENCE

Therapeutic Level II.

Challenges for interprofessional simulation-based sedation training courses: Mini review

Sedation for invasive procedures is given for various clinical purposes to patients of all ages worldwide. However, sedation is a continuum to general anesthesia and contains severe inherent risks leading to mortality. Providing a simulation-based sedation training course (SEDTC) to various medical staff could be an effective strategy to improve patient and medical safety associated with sedation. The SEDTC generally includes basic airway management such as upper airway obstruction release or rapid response action toward excessive sedation, utilizing problem-based learning or simulators. However, participation alone in the SEDTC can only achieve Level 1 (reaction) or 2 (learning) in the Kirkpatrick model. A patient safety improvement of Level 3 (transfer) or 4 (result) of the Kirkpatrick model can be achieved when all members related to sedation undergo experiential learning and reach a consensus. Accordingly, in-hospital interprofessional SEDTC focusing on a resilience approach is essential to achieve effective sedation patient safety in Level 3 or 4 of the Kirkpatrick model.

[Pulmonary function testing in the cat - an overview]

This article provides an overview of currently available pulmonary function tests in cats, divided into invasive and non-invasive methods. Invasive techniques comprise arterial blood gas analysis and measurement of pulmonary mechanics. Non-invasive techniques include pulse oximetry and capnography, as well as methods not yet integrated into everyday practice such as tidal breathing airflow-volume loops, whole-body barometric plethysmography and thorax compression. In this article, the background, execution, interpretation, and limitations of each test are discussed. Proper performance and assessment of pulmonary function measurements may aid in understanding the pathophysiology of feline respiratory disease and in increasing objectivity when assessing the existing disease and treatment efficacy.

[Analgesia for trauma patients in emergency medicine]

Adequate analgesia is one of the most important measures of emergency care in addition to treatment of vital function disorders and, if indicated, should be promptly undertaken; however, a large proportion of emergency patients receive no or only inadequate pain therapy. The numeric rating scale (NRS) is recommended for pain assessment but is not applicable to every group of patients; therefore, vital signs and body language should be included in the assessment. Pain therapy should reduce the NPRS to <5 points. Ketamine and fentanyl, which have an especially rapid onset of action, and also morphine are suitable for analgesia in spontaneously breathing patients. Basic prerequisites for safe and effective analgesia by healthcare professionals are the use of adequate monitoring, the provision of well-defined emergency equipment, and the mastery of emergency procedures. In a structured competence system, paramedics and nursing personnel can perform safe and effective analgesia.

Efficacy of ibuprofen in musculoskeletal post-traumatic pain in children: A systematic review

Musculoskeletal (MSK) injuries are one of the most frequent reason for pain-related evaluation in the emergency department (ED) in children. There is still no consensus as to what constitutes the best analgesic for MSK pain in children. However, ibuprofen is reported to be the most commonly prescribed analgesic and is considered the standard first-line treatment for MSK injury pain in children, even if it is argued that it provides inadequate relief for many patients. The purpose of this study was to review the most recent literature to assess the efficacy of ibuprofen for pain relief in MSK injuries in children evaluated in the ED. We performed a systematic review of randomized controlled trials on pharmacological interventions in children and adolescents under 19 years of age with MSK injuries according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The primary outcome was the risk ratio for successful reduction in pain scores. Six studies met the inclusion criteria and provided data on 1028 children. A meta-analysis was not performed since studies were not comparable due to the different analgesic treatment used. No significant difference in term of main pain score reduction between all the analgesics used in the included studies was noted. Patients who received oral opioids had side effects more frequently when compared to children who received ibuprofen. The combination of effect on pain relief and tolerability would suggest ibuprofen as the initial drug of choice in providing relief from mild-to-moderate MSK pain in children in the ED. The results obtained in this review and current research suggest that there’s no straightforward statistically significant evidence of the optimal analgesic agent to be used. However, ibuprofen may be preferable as the initial drug of choice in providing relief from MSK pain due to the favorable combination of effectiveness and safety profile. In fact, despite the non-significant pain reduction as compared to children who received opioids, there are less side effect associated to ibuprofen within studies. The wide range of primary outcomes measured in respect of pain scores and timing of recorded measures warrants a future standardization of study designs.

Pain Management for Orthopedic Injuries

Pain management in acute orthopedic injury needs to be tailored to the presentation and patient. Subjective and objective assessment, in conjunction with pathophysiology, should be used to provide symptom control. Ideally, treatment should be administered in an escalating fashion, attempting to manage pain with the lowest dose of the safest medication available. There are also adjunctive therapies, including those that are nonpharmacologic, that can provide additional relief.

Comparative study to evaluate dosimetric differences in patients of locally advanced carcinoma cervix undergoing intracavitary brachytherapy under two different anaesthesia techniques: an audit from a tertiary cancer centre in India

BACKGROUND

Carcinoma cervix is amongst the leading causes of mortality and morbidity in women population worldwide. High-dose-rate intracavitary brachytherapy (HDR-ICBT) post external beam radiation therapy (EBRT) is the standard of care in managing locally advanced stage cervical cancer patients. HDR-ICBT is generally performed under general anaesthesia (GA) in operation theatre (OT), but due to logistic reasons, sometimes, it becomes difficult to accommodate all patients under GA. Since prolonged overall treatment time (OTT) makes the results inferior, taking patients in day care setup under procedural sedation (PS) can be an effective alternative. In this audit, we tried to retrospectively analyse the dosimetric difference, if any, in patients who underwent ICBT at our centre, under either GA in OT or PS in day care.

RESULTS

Thirty five patients were analysed 16/35 (45.71%) patients underwent HDR-ICBT under GA while 19/35 (54.28%) patients under PS. In both groups, a statistically significant difference was observed between the dose received by 0.1 cc as well as 2 cc of rectum (p < 0.05), while the bladder and sigmoid colon had comparable dosages.

CONCLUSION

Though our dosimetric analysis highlighted better rectal sparing in patients undergoing HDR-ICBT under GA when compared to patients under PS, PS can still be considered an effective alternative, especially in centres dealing with significant patient load. Further studies are required for firm conclusion.

Assessment of procedural pain in French emergency departments: a multi-site, non-interventional, transverse study in patients with minor trauma injury

Objective: To determine the mean number of procedural painful episodes per patient, and to retrieve information regarding diagnosis, therapeutic procedures and analgesic management, in patients visiting Emergency Departments (EDs) for minor trauma. Methods: This observational, non-interventional, multicenter study in adult patients was performed in 35 French EDs. All patients entering the EDs for minor trauma on a specified day between noon and 10 pm were registered; consenting patients were included in the study. Pain intensity was assessed using a verbal Numerical Rating Scale from 0 (no pain) to 10 (worst possible pain). An episode was described as painful if the difference in pain intensity between pain just before the procedure and maximal pain during the procedure was ≥2. Two independent nurses recorded data on 1 day in each center. Results: Overall, 909 patients were registered, 422 were included in the study, and complete data for 409 patients (1899 procedures) were available for analysis. The mean number of painful episodes per patient was 1.0 ± 1.3. Fifty-one percent of patients reported at least one painful procedure episode. Twenty-one percent of procedures were considered painful. Clinical examination was the procedure most often reported as painful. No preventive or curative analgesic treatment was reported in 95.1% of procedures. Conclusions: There is a need for improvement in routine pain assessment and, therefore, procedural pain management for ED patients. Specific protocols should be developed for procedural pain management, and teams should be trained especially for procedures usually not considered painful.

Emergency Department Procedural Sedation Practice Limitations: A Statewide California American College of Emergency Physicians Survey

OBJECTIVES

We wanted to estimate the frequency and describe the nature of emergency department (ED) procedural sedation restrictions in the State of California.

METHODS

We surveyed medical directors for all licensed EDs statewide regarding limitations on procedural sedation practice. Our primary outcome was the frequency of restrictions on procedural sedation, defined as an inability to administer moderate sedation, deep sedation, and typical ED sedative agents in accordance with American College of Emergency Physicians (ACEP) guidelines. Our secondary outcomes were the nature of these restrictions, who has imposed them, why they were imposed, and the perceived clinical impact.

RESULTS

We obtained responses from 211 (64%) of the 328 EDs. Ninety-one (43%) reported conditional or total limitations on their ability to administer one or more of the following: moderate sedation, deep sedation, propofol, ketamine, or etomidate. Thirty-nine (18%) reported total restriction of at least one of these-most frequently a prohibition of deep sedation (18%). Local anesthesia directors were the most frequently cited creators and enforcers of these restrictions. Some respondents reported that, due to these restrictions, they used less effective sedatives, they performed procedures without sedation when sedation would have been preferred, and they observed inadequate sedation and pain control.

CONCLUSIONS

In this statewide survey we found a substantial prevalence of practice limitations-mostly created by local anesthesia directors-that restrict the ability of emergency physicians to provide procedural sedation for their patients in accordance with ACEP guidelines. Deep sedation was prohibited in 18% of responding EDs. Our respondents describe adverse consequences to patient care.

Effectiveness and safety of gastrointestinal endoscopy during a specific sedation training program for non-anesthesiologists

INTRODUCTION

sedation is a key component for the improvement of sedation quality. A correct administration requires appropriate training. We performed a study to compare sedation effectiveness, safety and patient satisfaction when administered by gastroenterologists, with and without specific training.

METHODS

a training program enrolled a group of gastroenterologists (trained group, n = 4) and their results were compared to those from a non-trained group (n = 3). ASA 1-3 patients who had undergone sedation by a gastroenterologist using midazolam and fentanyl were included over a period of 30 months. Safety was assessed in terms of the complication rate, effectiveness was assessed via the rate of completed endoscopic procedures and patient satisfaction was evaluated via a phone interview the day after the procedure.

RESULTS

a total of 3,475 patients were sedated by gastroenterologists during the study period. Significant differences were found that favored the trained group for completed procedures (5.6% vs 8.9%). A lower rate of excessive sedation (1.3% vs 8.61%), hypoxemia (0.72% vs 2.49%) and post-procedural pain (1.8% vs 4.3%) were also achieved. Patient satisfaction surpassed 99.5% and there were no significant differences between groups.

CONCLUSIONS

our sedation training program improved the effectiveness and safety outcomes when compared to sedation administered by gastroenterologists without this specific training.

Feasibility of measuring memory response to increasing dexmedetomidine sedation in children

BACKGROUND

The memory effect of dexmedetomidine has not been prospectively evaluated in children. We evaluated the feasibility of measuring memory and sedation responses in children during dexmedetomidine sedation for non-painful radiological imaging studies. Secondarily, we quantified changes in memory in relation to the onset of sedation.

METHODS

A 10 min bolus of dexmedetomidine (2 mcg kg^-1) was given to children as they named simple line drawings every five s. The absence of sedation was identified as any verbal response, regardless of correctness. After recovery, recognition memory was tested with correct Yes/No recognitions (50% novel pictures) and was matched to sedation responses during the bolus period (subsequent memory paradigm).

RESULTS

Of 64 accruals, 30 children (mean [SD]6.1 (1.2) yr, eight male) received dexmedetomidine and completed all study tasks. Individual responses were able to be modelled successfully in the 30 children completing all the study tasks, demonstrating feasibility of this approach. Children had 50% probability of verbal response at five min 40 s after infusion start, whereas 50% probability of subsequent recognition memory occurred sooner at four min five s.

CONCLUSIONS

Quantifying memory and sedation effects during dexmedetomidine infusion in verbal children was possible and demonstrated that memory function was present until shortly before verbal unresponsiveness occurred. This is the first study to investigate the effect of dexmedetomidine on memory in children.

CLINICAL TRIAL REGISTRATION

NCT 02354378.

Risk factors for bradypnea in a historical cohort of surgical patients receiving fentanyl-based intravenous analgesia

Introduction

The use of both pulse oximetry (SpO₂) and respiration rate (RR) monitoring is recommended to prevent the development of respiratory deterioration, particularly after extubation and narcotic analgesic use for pain management. In this study, we investigated the factors contributing to the development of bradypnea in surgical patients receiving fentanyl-based intravenous analgesia after general anesthesia.

Methods

This study involved a historical chart review of postoperative patients outside an intensive care unit setting. We divided the patients according to the data collected during the first hour postoperatively, into those developing bradypnea (RR < 8 breaths per min for > 2 min) and those with normal RR under oxygen administration. We defined oxygen desaturation as SpO₂ < 90% for > 10 s. We calculated the effect-site concentrations for fentanyl at the end of surgery and 1 h postoperatively using custom-made software based on chart records. A multivariable analysis was used to determine bradypnea-associated explanatory factors.

Results

For the final analysis, we included 258 patients. We detected bradypnea in 125 patients (48%) and oxygen desaturation in 46 patients (18%). We found no difference in the effect-site fentanyl concentrations between patients with and without bradypnea. The logistic regression model revealed that liver dysfunction [odds ratio (OR), 2.918; 95% confidence interval (CI), 1.329–6.405], renal dysfunction (OR, 0.349; 95% CI, 0.128–0.955), and smoking history (OR, 0.236; 95% CI, 0.075–0.735) were independently associated with bradypnea. We found similar incidences of oxygen desaturation between the groups.

Conclusions

Bradypnea was observed in 48% of postoperative patients receiving fentanyl-based intravenous analgesia under oxygen therapy. According to our results, impaired liver function associated positively, whereas smoking history associated negatively with its development. Renal dysfunction was paradoxically associated with less incidence of bradypnea.

Sedation: A Primer for Pediatricians

There has been an increasing use of pediatric procedural sedation and analgesia over the past 20 years, along with numerous medical and technological developments. Sedation can facilitate the smooth completion of otherwise stressful procedures, but it also can be associated with life-threatening complications. Pediatric practitioners need to be familiar with the basic tenets of providing safe and optimal sedation outside the operating room. This review focuses on the current understanding of sedation-related classification, guidelines, and medications, and discusses some special considerations for procedural sedation in common clinical settings. [Pediatr Ann. 2018;47(6):e254-e258.].

Hematoma block or procedural sedation and analgesia, which is the most effective method of anesthesia in reduction of displaced distal radius fracture?

Background

Procedure sedation and analgesia (PSA) is often used to alleviate discomfort and to facilitate fracture reduction for patients with distal radius fracture in emergency departments and clinics, but risks of respiratory distress and needs for different levels of monitoring under PSA are still under concern. Hematoma block (HB) is a simple alternative method of providing rapid pain relief during reduction of distal radius fracture. However, there is still in lack of strong evidence to promote HB over PSA in clinical practice. The aim of this study was to compare HB and PSA for adult and pediatric patients during reduction of displaced distal radius fracture to identify the level of pain relief, frequency of adverse effects (AEs), and reduction failure.

Methods

The PubMed, ScienceDirect, Cochrane Library, and ClinicalTrials.gov were searched for studies comparing HB or PSA in distal radius fracture reduction. The search revealed four randomized controlled trials and one non-randomized trial, which included two studies of pediatric subjects and three studies of adult subjects. Subgroup meta-analysis for adult and pediatric groups were specifically performed according to age difference to avoid potential bias.

Results

In the adult group, the effect of HB on post-reduction pain severity was better than that of PSA with significant heterogeneity (Hedges’ g − 0.600, 95% confidence interval (CI) − 1.170 to − 0.029, p = 0.039), although there was no difference on the pain severity during reduction between these two groups with significant heterogeneity (Hedges’ g 0.356, 95% CI − 1.101 to 1.812, p = 0.632). In the pediatric group, the treatment effect on pain severity was significantly better by HB than that by PSA but without significant heterogeneity (Hedges’ g − 0.402, 95% CI − 0.718 to − 0.085, p = 0.013, I² < 0.001%). Most of the reported adverse effects (AEs) include nausea, vomiting, and respiratory distress developed in adult patients treated by PSA. The rates of reported AEs did not significantly differ between HB and PSA in the pediatric group. Additionally, final outcomes of reduction failure did not significantly differ between HB and PSA in both adult and pediatric groups.

Conclusion

Hematoma block is a safe and effective alternative of anesthesia in reduction of distal radius fracture without inferior pain relief compared with PSA among adult and pediatric patients.

Electronic supplementary material

The online version of this article (10.1186/s13018-018-0772-7) contains supplementary material, which is available to authorized users.

Battlefield Analgesia in Tactical Combat Casualty Care

At the start of the Afghanistan conflict, battlefield analgesia for US military casualties was achieved primarily through the use of intramuscular (IM) morphine. This is a suboptimal choice, since IM morphine is slow-acting, leading to delays in effective pain relief and the risk of overdose and death when dosing is repeated in order to hasten the onset of analgesia. Advances in battlefield analgesia, pioneered initially by Tactical Combat Casualty Care (TCCC), and the Army's 75th Ranger Regiment, have now been incorporated into the Triple-Option Analgesia approach. This novel strategy has gained wide acceptance in the US military. It calls for battlefield analgesia to be achieved using 1 or more of 3 options depending on the casualty's status: 1) the meloxicam and acetaminophen in the combat wound medication pack (CWMP) for casualties with relatively minor pain that are still able to function effectively as combatants if their sensorium is not altered by analgesic medications; 2) oral transmucosal fentanyl citrate (OTFC) for casualties who have moderate to severe pain, but who are not in hemorrhagic shock or respiratory distress, and are not at significant risk for developing either condition; or 3) ketamine for casualties who have moderate to severe pain, but who are in hemorrhagic shock or respiratory distress or are at significant risk for developing either condition. Ketamine may also be used to increase analgesic effect for casualties who have previously been given opioid medication. The present paper outlines the evolution and evidence base for battlefield analgesia as currently recommended by TCCC. It is not intended to be a comprehensive review of all prehospital analgesic options.

Using continuous quantitative capnography for emergency department procedural sedation: a systematic review and cost-effectiveness analysis

End-tidal CO₂ has been advocated to improve safety of emergency department (ED) procedural sedation by decreasing hypoxia and catastrophic outcomes. This study aimed to estimate the cost-effectiveness of routine use of continuous waveform quantitative end-tidal CO₂ monitoring for ED procedural sedation in prevention of catastrophic events. Markov modeling was used to perform cost-effectiveness analysis to estimate societal costs per prevented catastrophic event (death or hypoxic brain injury) during routine ED procedural sedation. Estimates for efficacy of capnography and safety of sedation were derived from the literature. This model was then applied to all procedural sedations performed in US EDs with assumptions selected to maximize efficacy and minimize cost of implementation. Assuming that capnography decreases the catastrophic adverse event rate by 40.7% (proportional to efficacy in preventing hypoxia), routine use of capnography would decrease the 5-year estimated catastrophic event rate in all US EDs from 15.5 events to 9.2 events (difference 6.3 prevented events per 5 years). Over a 5-year period, implementing routine end-tidal CO₂ monitoring would cost an estimated $2,830,326 per prevented catastrophic event, which translates into $114,007 per quality-adjusted life-year. Sensitivity analyses suggest that reasonable assumptions continue to estimate high costs of prevented catastrophic events. Continuous waveform quantitative end-tidal CO₂ monitoring is a very costly strategy to prevent catastrophic complications of procedural sedation when applied routinely in ED procedural sedations.

Böttiger B, Bouillon B, Fischer M, Gaier G, Gliwitzky B, Helm M, Hilbert-Carius P, Hossfeld B, Meisner C, Schempf B, Wafaisade A, Bernhard M. Analgesia in Patients with Trauma in Emergency Medicine

BACKGROUND

Suitable analgesic drugs and techniques are needed for the acute care of the approximately 18 200-18 400 seriously injured patients in Germany each year.

METHODS

This systematic review and meta-analysis of analgesia in trauma patients was carried out on the basis of randomized, controlled trials and observational studies. A systematic search of the literature over the 10-year period ending in February 2016 was carried out in the PubMed, Google Scholar, and Springer Link Library databases. Some of the considered trials and studies were included in a meta-analysis. Mean differences (MD) of pain reduction or pain outcome as measured on the Numeric Rating Scale were taken as a summarizing measure of treatment efficacy.

RESULTS

Out of 685 studies, 41 studies were considered and 10 studies were included in the meta-analysis. Among the drugs and drug combinations studied, none was clearly superior to another with respect to pain relief. Neither fentanyl versus morphine (MD -0.10 with a 95% confidence interval of [-0.58; 0.39], p = 0.70) nor ketamine versus morphine (MD -1.27 [-3.71; 1.16], p = 0.31), or the combination of ketamine and morphine versus morphine alone (MD -1.23 [-2.29; -0.18], p = 0.02) showed clear superiority regarding analgesia.

CONCLUSION

Ketamine, fentanyl, and morphine are suitable for analgesia in spontaneously breathing trauma patients. Fentanyl and ketamine have a rapid onset of action and a strong analgesic effect. Our quantitative meta-analysis revealed no evidence for the superiority of any of the three substances over the others. Suitable monitoring equipment, and expertise in emergency procedures are prerequisites for safe and effective analgesia by healthcare professionals..

Complications associated with intravenous midazolam and fentanyl sedation in patients undergoing minor oral surgery

Background

Anxiety control remains an important concern in dental practice. We evaluated the incidence, nature, and sequelae of complications during and after minor oral surgeries performed under intravenous midazolam and fentanyl sedation using the titration technique.

Methods

The medical records of patients who had undergone minor oral surgeries under moderate intravenous midazolam and fentanyl sedation at our institution between January 1, 2015 and December 31, 2015 were retrospectively evaluated. Age, sex, body mass index, medical history, American Society of Anesthesiologists (ASA) classification, indications for sedation, amount of sedative used, surgical duration, and recovery time were evaluated for all patients.

Results

In total, 107 patients aged 9–84 years were included. ASA class I and class II were observed for 56.1% and 43.9% patients, respectively. Complications associated with sedation occurred in 11 (10.2%) patients. There were no serious adverse events. Oxygen saturation reached 95% during the procedure in six patients; this was successfully managed by stimulating the patients to take a deep breath. Two patients exhibited deep sedation and one exhibited paradoxical excitement. After the procedure, one patient experienced nausea without vomiting and one exhibited a prolonged recovery time. The surgical procedures were completed in all patients. Obesity was found to be significantly associated with sedation-related complications.

Conclusions

Our results suggest that complications associated with intravenous midazolam and fentanyl sedation using the titration technique for minor oral surgeries are mostly minor and can be successfully managed with no prolonged sequelae.

Evaluating Patient-Centered Outcomes in Clinical Trials of Procedural Sedation, Part 1 Efficacy: Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations

The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research, established by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks public-private partnership with the US Food and Drug Administration, convened a meeting of sedation experts from a variety of clinical specialties and research backgrounds with the objective of developing recommendations for procedural sedation research. Four core outcome domains were recommended for consideration in sedation clinical trials: (1) safety, (2) efficacy, (3) patient-centered and/or family-centered outcomes, and (4) efficiency. This meeting identified core outcome measures within the efficacy and patient-centered and/or family-centered domains. Safety will be addressed in a subsequent meeting, and efficiency will not be addressed at this time. These measures encompass depth and levels of sedation, proceduralist and patient satisfaction, patient recall, and degree of pain experienced. Consistent use of the recommended outcome measures will facilitate the comprehensive reporting across sedation trials, along with meaningful comparisons among studies and interventions in systematic reviews and meta-analyses.

A Novel Strategy to Reverse General Anesthesia by Scavenging with the Acyclic Cucurbit[n]uril-type Molecular Container Calabadion 2

BACKGROUND

Calabadion 2 is a new drug-encapsulating agent. In this study, the authors aim to assess its utility as an agent to reverse general anesthesia with etomidate and ketamine and facilitate recovery.

METHODS

To evaluate the effect of calabadion 2 on anesthesia recovery, the authors studied the response of rats to calabadion 2 after continuous and bolus intravenous etomidate or ketamine and bolus intramuscular ketamine administration. The authors measured electroencephalographic predictors of depth of anesthesia (burst suppression ratio and total electroencephalographic power), functional mobility impairment, blood pressure, and toxicity.

RESULTS

Calabadion 2 dose-dependently reverses the effects of ketamine and etomidate on electroencephalographic predictors of depth of anesthesia, as well as drug-induced hypotension, and shortens the time to recovery of righting reflex and functional mobility. Calabadion 2 displayed low cytotoxicity in MTS-3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium-based cell viability and adenylate kinase release cell necrosis assays, did not inhibit the human ether-à-go-go-related channel, and was not mutagenic (Ames test). On the basis of maximum tolerable dose and acceleration of righting reflex recovery, the authors calculated the therapeutic index of calabadion 2 in recovery as 16:1 (95% CI, 10 to 26:1) for the reversal of ketamine and 3:1 (95% CI, 2 to 5:1) for the reversal of etomidate.

CONCLUSIONS

Calabadion 2 reverses etomidate and ketamine anesthesia in rats by chemical encapsulation at nontoxic concentrations.

The information needs of patients receiving procedural sedation in a hospital emergency department

This research investigated the information needs of patients receiving ED procedural sedation to determine the best format to consistently deliver key information in a way acceptable to all involved. Of particular interest was the question concerning patients' need for receiving written information. A descriptive exploratory study gathered qualitative data through face-to-face interviews and focus groups involving patients, nurses and medical staff. Individual interviews were conducted with eight adult patients following procedural sedation. They identified very few gaps in terms of specific information they needed pertaining to procedural sedation and rejected the need for receiving information in a written format. Their information needs related to a central concern for safety and trust. Focus groups, reflecting on the findings from patients, were conducted with five ED nurses and four emergency medicine consultants/registrars who regularly provided procedural sedation. Themes that emerged from the analysis of data from all three groups identified the issues concerning patient information needs as being: competence and efficiency of staff; explanations of procedures and progress; support person presence; and medico-legal issues. The research confirms that the quality of the patient's ED experience, specifically related to procedural sedation, is enhanced by ED staff, especially nurses, providing them with ongoing and repeated verbal information relevant to their circumstances.

Capnography versus standard monitoring for emergency department procedural sedation and analgesia

BACKGROUND

Procedural sedation and analgesia (PSA) is used frequently in the emergency department (ED) to facilitate painful procedures and interventions. Capnography, a monitoring modality widely used in operating room and endoscopy suite settings, is being used more frequently in the ED setting with the goal of reducing cardiopulmonary adverse events. As opposed to settings outside the ED, there is currently no consensus on whether the addition of capnography to standard monitoring modalities reduces adverse events in the ED setting.

OBJECTIVES

To assess whether capnography in addition to standard monitoring (pulse oximetry, blood pressure and cardiac monitoring) is more effective than standard monitoring alone to prevent cardiorespiratory adverse events (e.g. oxygen desaturation, hypotension, emesis, and pulmonary aspiration) in ED patients undergoing PSA.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (2016, Issue 8), and MEDLINE, Embase, and CINAHL to 9 August 2016 for randomized controlled trials (RCTs) and quasi-randomized trials of ED patients requiring PSA with no language restrictions. We searched meta-registries (www.controlled-trials.com, www.clinicalstudyresults.org, and clinicaltrials.gov) for ongoing trials (February 2016). We contacted the primary authors of included studies as well as scientific advisors of capnography device manufacturers to identify unpublished studies (February 2016). We handsearched conference abstracts of four organizations from 2010 to 2015.

SELECTION CRITERIA

We included any RCT or quasi-randomized trial comparing capnography and standard monitoring to standard monitoring alone for ED patients requiring PSA.

DATA COLLECTION AND ANALYSIS

Two authors independently performed study selection, data extraction, and assessment of methodological quality for the 'Risk of bias' tables. An independent researcher extracted data for any included studies that our authors were involved in. We contacted authors of included studies for incomplete data when applicable. We used Review Manager 5 to combine data and calculate risk ratios (RR) and 95% confidence intervals (CI) using both random-effects and fixed-effect models.

MAIN RESULTS

We identified three trials (κ = 1.00) involving 1272 participants. Comparing the capnography group to the standard monitoring group, there were no differences in the rates of oxygen desaturation (RR 0.89, 95% CI 0.48 to 1.63; n = 1272, 3 trials; moderate quality evidence) and hypotension (RR 2.36, 95% CI 0.98 to 5.69; n = 986, 1 trial; moderate quality evidence). There was only one episode of emesis recorded without significant difference between the groups (RR 3.10, 95% CI 0.13 to 75.88, n = 986, 1 trial; moderate quality evidence). The quality of evidence for the primary outcomes was moderate with downgrades primarily due to heterogeneity and reporting bias.There were no differences in the rate of airway interventions performed (RR 1.26, 95% CI 0.94 to 1.69; n = 1272, 3 trials; moderate quality evidence). In the subgroup analysis, we found a higher rate of airway interventions for adults in the capnography group (RR 1.44, 95% CI 1.16 to 1.79; n = 1118, 2 trials; moderate quality evidence) with a number needed to treat for an additional harmful outcome of 12. Although statistical heterogeneity was reduced, there was moderate quality of evidence due to outcome definition heterogeneity and limited reporting bias. None of the studies reported recovery time.

AUTHORS' CONCLUSIONS

There is a lack of convincing evidence that the addition of capnography to standard monitoring in ED PSA reduces the rate of clinically significant adverse events. Evidence was deemed to be of moderate quality due to population and outcome definition heterogeneity and limited reporting bias. Our review was limited by the small number of clinical trials in this setting.

[Prehospital analgesia by emergency physicians and paramedics : Comparison of effectiveness]

BACKGROUND

In some German emergency medical service districts, analgesia is performed by paramedics without support of emergency physicians on scene. With regard to safety and effectiveness, paramedics should not be overshadowed by emergency physicians.

OBJECTIVES

Is prehospital analgesia performed by paramedics under medical supervision or emergency physicians comparable regarding processes and effectiveness in the case of isolated limb injury?

MATERIAL AND METHODS

As a retrospective analysis of patients with isolated limb injury, analgesia performed by paramedics and by emergency physicians was analyzed. In addition to pain reduction, prescribed monitoring, and further airway maneuvers, vital parameters (Glasgow coma scale, systolic blood pressure, heartrate and respiratory rate, oxygen saturation) were recorded at the beginning and end of prehospital treatment.

RESULTS

Pain was reduced from NRS 8 ± 1 to NRS 2 ± 1 in the paramedic group, and from NRS 8 ± 2 to NRS 2 ± 2 in the physician group, so the mean pain reduction was 6 ± 2 in the paramedic-group and 5 ± 2 in the physician group (p < 0.001). Adequate analgesia was found in 96.9% in the physician group and 91.7% in the paramedic group (p = 0.113). ECG monitoring and oxygen administration according to SOP was significantly more frequent in the paramedic group than in the physician group (p < 0.001). Respiratory frequency was significantly more frequent in the physician group than in the paramedic group (p < 0.001).

CONCLUSIONS

The study shows, with a given indication, that German paramedics can independently perform safe and successful analgesia under medical supervision.

Extended Monitoring during Endoscopy

Gastrointestinal endoscopic sedation has improved procedural and patient outcomes but is associated with attendant risks of oversedation and hemodynamic compromise. Therefore, close monitoring during endoscopic procedures using sedation is critical. This monitoring begins with appropriate staff trained in visual assessment of patients and analysis of basic physiologic parameters. It also mandates an array of devices widely used in practice to evaluate hemodynamics, oxygenation, ventilation, and depth of sedation. The authors review the evidence behind monitoring practices and current society recommendations and discuss forthcoming technologies and techniques that are poised to improve noninvasive monitoring of patients under endoscopic sedation.

Incidence of adverse events in paediatric procedural sedation in the emergency department: a systematic review and meta-analysis

OBJECTIVE AND DESIGN

We conducted a systematic review and meta-analysis to evaluate the incidence of adverse events in the emergency department (ED) during procedural sedation in the paediatric population. Randomised controlled trials and observational studies from the past 10 years were included. We adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

SETTING

ED.

PARTICIPANTS

Children.

INTERVENTIONS

Procedural sedation.

OUTCOMES

Adverse events like vomiting, agitation, hypoxia and apnoea. Meta-analysis was performed with random-effects model and reported as incidence rates with 95% CIs.

RESULTS

A total of 1177 studies were retrieved for screening and 258 were selected for full-text review. 41 studies reporting on 13 883 procedural sedations in 13 876 children (≤18 years) were included. The most common adverse events (all reported per 1000 sedations) were: vomiting 55.5 (CI 45.2 to 65.8), agitation 17.9 (CI 12.2 to 23.7), hypoxia 14.8 (CI 10.2 to 19.3) and apnoea 7.1 (CI 3.2 to 11.0). The need to intervene with either bag valve mask, oral airway or positive pressure ventilation occurred in 5.0 per 1000 sedations (CI 2.3 to 7.6). The incidences of severe respiratory events were: 34 cases of laryngospasm among 8687 sedations (2.9 per 1000 sedations, CI 1.1 to 4.7; absolute rate 3.9 per 1000 sedations), 4 intubations among 9136 sedations and 0 cases of aspiration among 3326 sedations. 33 of the 34 cases of laryngospasm occurred in patients who received ketamine.

CONCLUSIONS

Serious adverse respiratory events are very rare in paediatric procedural sedation in the ED. Emesis and agitation are the most frequent adverse events. Hypoxia, a late indicator of respiratory depression, occurs in 1.5% of sedations. Laryngospasm, though rare, happens most frequently with ketamine. The results of this study provide quantitative risk estimates to facilitate shared decision-making, risk communication, informed consent and resource allocation in children undergoing procedural sedation in the ED.

Pain Management of Pediatric Musculoskeletal Injury in the Emergency Department: A Systematic Review

Background. Pain management for children with musculoskeletal injuries is suboptimal and, in the absence of clear evidence-based guidelines, varies significantly. Objective. To systematically review the most effective pain management for children presenting to the emergency department with musculoskeletal injuries. Methods. Electronic databases were searched systematically for randomized controlled trials of pharmacological and nonpharmacological interventions for children aged 0-18 years, with musculoskeletal injury, in the emergency department. The primary outcome was the risk ratio for successful reduction in pain scores. Results. Of 34 studies reviewed, 8 met inclusion criteria and provided data on 1169 children from 3 to 18 years old. Analgesics used greatly varied, making comparisons difficult. Only two studies compared the same analgesics with similar routes of administration. Two serious adverse events occurred without fatalities. All studies showed similar pain reduction between groups except one study that favoured ibuprofen when compared to acetaminophen. Conclusions. Due to heterogeneity of medications and routes of administration in the articles reviewed, an optimal analgesic cannot be recommended for all pain categories. Larger trials are required for further evaluation of analgesics, especially trials combining a nonopioid with an opioid agent or with a nonpharmacological intervention.

Comparative study of hyoscine doses as antisialagogue for patients receiving ketofol sedation undergoing colonoscopy procedures

Objective:

To compare the effects of different regimens of hyoscine as antisialagogue in patients undergoing ketofol sedation for colonoscopy procedures.

Patients and Methods:

In this prospective double-blind randomized controlled trial 200 American Society of Anesthesiologists I-II aged 20–60-year-old undergoing colonoscopy were randomly assigned into four equal groups, group A received 5 mg hyoscine intravenous, group B received 10 mg, group C received 20 mg intravenous, and control group (D) that was received saline. All patients were sedated using ketofol titrated to achieve Ramsey Sedation Score 4, hemodynamic variables and occurrence of increased secretions were evaluated and recorded.

Results:

Hyoscine in a dose of 10 mg was the optimum dose to achieve least salivation with the least side effect while hyoscine 5 mg was not efficient to achieve dry field or good surgical conditions. However, hyoscine 20 mg achieved dry field and fair surgical conditions in expenses of tachycardia.

Conclusion:

Hyoscine 10 mg was the least effective dose that significantly reduced hypersalivation in patients receiving ketofol sedation for colonoscopy procedures, this dose was as effective as 20 mg in draying secretion but with significantly less tachycardia.

Emergency department procedural sedation and analgesia: A Canadian Community Effectiveness and Safety Study (ACCESS)

Objectives:

To determine the effectiveness and safety of procedural sedation and analgesia (PSA) in a Canadian community emergency department (ED) staffed primarily by family physicians and to assess the role of capnometry monitoring in PSA.

Methods:

One hundred and sixty (160) consecutive procedural sedation cases were reviewed from the ED of a rural hospital in Huntsville, Ont. The ED is mainly staffed by family physicians who have received in-house training in PSA. Safety and effectiveness measures were extrapolated from a standardized PSA form by a blinded research assistant.

Results:

The mean age of the patient population was 33.6 years (standard deviation = 23.6). Fifty-four percent of the patients were male, and 33% of the cases were pediatric. PSA medications included propofol (84%), fentanyl (51%) and midazolam (15%), and the procedural success rate was 95.6%. The adverse event (AE) rate was 18% and included apnea (10%), inadequate sedation (3%), bradycardia (2%), desaturation (1%), hypotension (1%) and bag-valve-mask use (1%). In those aged ≥65 years there was a greater incidence of apnea. There were no episodes of emesis and there were no intubations. A modified jaw thrust manoeuvre was used in 23% of the cases. In the 64% of cases where capnometry was used, there was no association between its use and any AE measures.

Conclusion:

Procedural sedation was safe and effective in our environment. Capnometry recording did not appear to alter outcomes, although the data are incomplete.

Impact of a multifaceted pediatric sedation course: self-directed learning versus a formal continuing medical education course to improve knowledge of sedation guidelines

Background:

Procedural sedation guidelines were established for a tertiary care pediatric emergency department (ED). We developed a pediatric procedural sedation course to disseminate these guidelines.

Objective:

Our objective was to evaluate the effectiveness of a sedation course in improving physicians' knowledge of pediatric procedural sedation practices and guidelines, relative to individual self-directed learning.

Methods:

We recruited emergency staff physicians and fellows as well as fourth-year pediatric residents in a tertiary care pediatric ED to participate in a randomized, controlled, educational intervention. All consenting physicians received pediatric sedation educational material for individual study 2 weeks before a learning assessment. Participants were randomly assigned to one of 2 groups. The self-directed learning group (n= 24) completed a multiple-choice examination without receiving any formal teaching. The study group (n= 24) participated in a 4-hour formal multi-faceted sedation course before writing the multiple-choice examination.

Results:

The groups did not differ significantly in demographic characteristics or self-perceived knowledge of pediatric sedation. The formal teaching group's median examination score (83.3%; range 75.8%–96.5%) was significantly higher (p&lt; 0.0001) than the median examination score of participants in the self-directed study group (73.3%, range 43.5%–86.6%).

Conclusion:

The multifaceted sedation course was more effective in improving physician knowledge and understanding of sedation guidelines and practices than unstructured, self-directed learning.

A comparative evaluation of capnometry versus pulse oximetry during procedural sedation and analgesia on room air

Objective:

Important questions remain regarding how best to monitor patients during procedural sedation and analgesia (PSA). Capnometry can detect hypoventilation and apnea, yet it is rarely used in emergency patients. Even the routine practice of performing preoxygenation in low-risk patients is controversial, as supplementary oxygen can delay the detection of respiratory depression by pulse oximetry. The purpose of this study was to determine whether the capnometer or the pulse oximeter would first detect respiratory events in adults breathing room air.

Methods:

During a randomized clinical trial comparing fentanyl with low-dose ketamine for PSA with titrated propofol, patients were monitored using pulse oximetry and continuous oral–nasal sampled capnography. Supplemental oxygen was administered only for oxygen desaturation. Sedating physicians identified prespecified respiratory events, including hypoventilation (end-tidal carbon dioxide &gt; 50 mm Hg, rise of 10 mm Hg from baseline or loss of waveform) and oxygen desaturation (pulse oximetry &lt; 92%). These events and their timing were corroborated by memory data retrieved from the monitors.

Results:

Of 63 patients enrolled, 57% (36) developed brief oxygen desaturation at some point during the sedation. All responded to oxygen, stimulation or interruption of propofol. Measurements of end-tidal carbon dioxide varied substantially between and within patients before study intervention. Hypoventilation (19 patients, 30%) was only weakly associated with oxygen desaturation (crude odds ratio 1.4 [95% confidence interval 0.47 to 4.3]), and preceded oxygen desaturation in none of the 12 patients in whom both events occurred (median lag 1:50 m:ss [interquartile range 0:01 to 3:24 m:ss]).

Conclusion:

During PSA in adults breathing room air, desaturation detectable by pulse oximeter usually occurs before overt changes in capnometry are identified.

Efficacy, safety and patient satisfaction of propofol for procedural sedation and analgesia in the emergency department: a prospective study

Objective:

We evaluated the efficacy, safety and patient satisfaction with the use of propofol for procedural sedation and analgesia in the emergency department (ED).

Methods:

All patients receiving propofol for procedural sedation and analgesia in the ED between December 1, 2003, and November 30, 2005, were prospectively assessed. Propofol was administered using a standardized protocol, which included an initial dose of 0.25–0.5 mg/kg followed by 10–20 mg/minute until sedated. Efficacy was evaluated using procedural success rate, recovery time and physician satisfaction. Adverse respiratory effects were defined as apnea for more than 30 seconds or an oxygen saturation of less than 90%. Hypotension was defined as systolic blood pressure &lt; 90 mm Hg or &gt; 20% decrease from baseline. Patient and physician satisfaction were determined using 5-point Likert scales.

Results:

Our study included 113 patients with a mean age of 50 (standard deviation [SD] 19) years; 62% were male. The most common procedures were orthopedic manipulation (44%), cardioversion (37%), and abscess incision and drainage (13%). The mean total propofol dose required was 1.6 (SD 0.9) mg/kg. Procedural success was achieved in 90% of cases and the mean patient recovery time was 7.6 (SD 3.4) minutes. No patient (0%, 95% confidence interval [CI] 0%–3%) experienced apnea; however, 1 patient (1%, 95% CI 0%–5%) experienced emesis, which resulted in an oxygen saturation &lt;90%. Nine patients (8%, 95% CI 4%–15%) experienced hypotension and 7 (6%, 95% CI 3%–12%) experienced pain on injection. All patients were very satisfied (92%, 95% CI 85%–96%) or satisfied (8%, 95% CI 4%–15%), and 94% (95% CI 88%–98%) reported no recollection of the procedure. The majority of physicians were very satisfied (85%, 95% CI 77%–91%) or satisfied (6%, 95% CI 3%–12%) with the sedation and the conditions achieved.

Conclusion:

When administered as part of a standardized protocol, propofol appears to be a safe and effective agent for performing procedural sedation and analgesia in the ED, and is associated with high patient and physician satisfaction.

Procedural sedation and analgesia in a Canadian adult tertiary care emergency department: a case series

Objectives:

To examine the safety of emergency department (ED) procedural sedation and analgesia (PSA) and the patterns of use of pharmacologic agents at a Canadian adult teaching hospital.

Methods:

Retrospective analysis of the PSA records of 979 patients, treated between Aug. 1, 2004, and July 31, 2005, with descriptive statistical analysis. This represents an inclusive consecutive case series of all PSAs performed during the study period.

Results:

Hypotension (systolic blood pressure ≤ 85 mm Hg) was documented during PSA in 13 of 979 patients (1.3%; 95% confidence interval [CI] 0.3%–2.3%), and desaturation (Sao2≤ 90) in 14 of 979 (1.4%; CI 0.1%–2.7%). No cases of aspiration, endotracheal intubation or death were recorded. The most common medication used was fentanyl (94.0% of cases), followed by propofol (61.2%), midazolam (42.5%) and then ketamine (2.7%). The most frequently used 2-medication combinations were propofol and fentanyl (P/F) followed by midazolam and fentanyl (M/F), used with similar frequencies 58.1% (569/979) and 41.0% (401/979) respectively. There was no significant difference in the incidence of hypotension or desaturation between the P/F and M/F treated groups. In these patients, 9.1% (90/979) of patients received more than 2 different drugs.

Conclusions:

Adverse events during ED PSA are rare and of doubtful clinical significance. Propofol/fentanyl and midazolam/fentanyl are used safely, and at similar frequencies for ED PSA in this tertiary hospital case series. The use of ketamine for adult PSA is unusual in our facility.

Procedural Sedation Practice: A Review of Current Nursing Standards

Although administration of procedural sedation is a common practice among nurses, at present a unified consensus statement on Registered Nurse (RN) sedation core competencies or a consistent way in which RN sedation practice is regulated in the United States is lacking. In this article, the topic of RN sedation is discussed and includes current sedation standards by the American Society of Anesthesiologists and the Joint Commission. Examples of current regulations from State Boards of Nursing throughout the United States are also reviewed. Three major controversies related to RN sedation practice exist: variation in Board of Nursing regulation, lack of research on RN sedation practice, and lack of a national standard for RN sedation. Recommendations to address each of these areas are provided to inform regulators and nurse educators about current standards and knowledge gaps in sedation care. Strategies to improve sedation research in order to advance practice in this area are also discussed.