Propofol for procedural sedation in the pediatric emergency department

Independent risk factors for adverse events associated with propofol-based pediatric sedation performed by anesthesiologists in the radiology suite: a prospective observational study

This study aimed to identify the types and frequencies of adverse events, as well as the risk factors for respiratory complications related to pediatric sedation. This single-center, prospective, observational study was conducted in a radiology suite at a tertiary university hospital for 2 years. Patients aged under 18 years, who underwent sedation solely by anesthesiologists for computed tomography or magnetic resonance imaging scans, were eligible for inclusion. Univariate and multivariate logistic regression analyses were carried out to identify the risk factors of adverse events, including respiratory complications, related to the propofol-based sedation. We further performed a sensitivity test with 1-to-5 propensity score matching analysis to assess the robustness of our findings. Among 2569 children, 3.9% experienced respiratory problems related to the sedation. After 1-to-5 propensity matching analysis, cardiac and neurologic comorbidities, crying before sedation, a history of snoring or upper respiratory infection, and prolonged duration of sedation were independently associated with the occurrence of adverse respiratory events.Conclusions: Our protocol for pediatric sedation demonstrates a high success rate and low likelihood of fatal complications, but proactive management prior to propofol-based sedation is critical to prevent adverse respiratory events in children. What is Known: • Propofol-based pediatric sedation is associated with adverse events necessarily even though performed by professional anesthesiologists solely. What is New: • Cardiac and neurologic comorbidities, crying before sedation, a history of snoring or upper respiratory infection, and prolonged duration of sedation were independently associated with the occurrence of respiratory adverse events. • Proactive management prior to sedation is critical to preventing adverse respiratory events for pediatrics.

Safety and Efficacy of a Propofol and Ketamine Based Procedural Sedation Protocol in Children with Cerebral Palsy Undergoing Botulinum Toxin A Injections

BACKGROUND

Pediatric patients with cerebral palsy often undergo intramuscular botulinum toxin (BoNT-A) injections. These injections can be painful and may require procedural sedation. An ideal sedation protocol has yet to be elucidated.

OBJECTIVE

To investigate the safety and efficacy of a propofol and ketamine based sedation protocol in pediatric patients with cerebral palsy requiring BoNT-A injections.

DESIGN

Retrospective chart review.

SETTING

The sedations took place in a procedural sedation suite at a tertiary children's hospital from February 2013 through September 2017.

PATIENTS

164 patients with diagnoses of cerebral palsy undergoing propofol and ketamine based sedation for injections with botulinum toxin A.

METHODS

An initial bolus of 0.5 mg/kg ketamine followed by a 2 mg/kg bolus of propofol was administered with supplemental boluses of propofol as needed to achieve deep sedation during the intramuscular BoNT-A injections.

MAIN OUTCOME MEASUREMENTS

Propofol dosages, adverse events, serious adverse events, and sedation time parameters were reviewed.

RESULTS

345 sedations were successfully performed on 164 patients. The median total dose of propofol was 4.7 mg/kg (interquartile range [IQR]: 3.5, 6.3). Adverse events were encountered in 10.1% of procedures including hypoxemia responsive to supplemental oxygen (9.6%) and transient apnea (1.4%). The mean procedure time, recovery time, and total sedation time were 10, 11 and 33 minutes, respectively. With regard to patient variables, including age, weight, dose of propofol, sedation time, and Gross Motor Function Classification System classification, there was no association with increased incidence of adverse events.

CONCLUSION

Our sedation protocol of propofol and ketamine is safe and effective in children with cerebral palsy undergoing procedural sedation for intramuscular injections with BoNT-A. The adverse events encountered appeared to be related to airway and respiratory complications secondary to musculoskeletal deformities, emphasizing the importance of airway monitoring and management in these patients.

LEVEL

IV.

Comparison between chloral hydrate and propofol-ketamine as sedation regimens for pediatric auditory brainstem response testing

Introduction

The use of diagnostic auditory brainstem response testing under sedation is currently the “gold standard” in infants and young children who are not developmentally capable of completing the test.

Objective

The aim of the study is to compare a propofol-ketamine regimen to an oral chloral hydrate regimen for sedating children undergoing auditory brainstem response testing.

Methods

Patients between 4 months and 6 years who required sedation for auditory brainstem response testing were included in this retrospective study. Drugs doses, adverse effects, sedation times, and the effectiveness of the sedative regimens were reviewed.

Results

73 patients underwent oral chloral hydrate sedation, while 117 received propofol-ketamine sedation. 12% of the patients in the chloral hydrate group failed to achieve desired sedation level. The average procedure, recovery and total nursing times were significantly lower in the propofol-ketamine group. Propofol-ketamine group experienced higher incidence of transient hypoxemia.

Conclusion

Both sedation regimens can be successfully used for sedating children undergoing auditory brainstem response testing. While deep sedation using propofol-ketamine regimen offers more efficiency than moderate sedation using chloral hydrate, it does carry a higher incidence of transient hypoxemia, which warrants the use of a highly skilled team trained in pediatric cardio-respiratory monitoring and airway management.

Procedural Sedation With Ketamine Versus Propofol for Closed Reduction of Pediatric Both Bone Forearm Fractures

Effective treatment of pediatric both bone forearm fractures consists of timely restoration of anatomic alignment with manipulation and immobilization, often accomplished with the aid of procedural sedation in the emergency department setting. The current lack of consensus regarding a safe and optimal regimen may result in inadequate sedation, compromised quality of reduction, or patient harm. The current study was conducted to answer the following questions for pediatric both bone forearm fractures treated with closed reduction with either ketamine or propofol procedural sedation: (1) Is there a difference in the rate of unacceptable alignment 4 weeks after reduction? (2) Is there a difference in the rates of major sedation-related complications? Medical records, data on procedural sedation, and radiographs of 74 skeletally immature patients with diaphyseal or distal metaphyseal both bone forearm fractures treated with manipulation were reviewed (ketamine sedation, 26; propofol sedation, 48). Rates of unacceptable alignment for the 2 cohorts were similar both immediately after reduction and at 4 weeks. Rates of complications of procedural sedation did not differ between cohorts. The duration of procedural sedation was longer and the padding index was greater with ketamine. Malalignment after reduction was more likely in older patients and those with a higher padding index. Although no difference was found in the rates of malalignment or sedation-related complications between fractures reduced with ketamine or propofol sedation, the sedation regimens differ in both procedural duration and padding index. Careful consideration of the risks and benefits of procedural sedation for closed reduction of pediatric forearm fractures is warranted. [Orthopedics. 2017; 40(5):288-294.].

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.

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 < 90 mm Hg or > 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 <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.

Pediatric procedural sedation with propofol using a higher initial bolus dose

OBJECTIVES

We sought to describe the doses of propofol used for sedation in our pediatric emergency department, along with the range of procedures performed under propofol sedation. We also planned to describe clinically important physiologic changes seen and physician satisfaction with propofol at the doses observed.

METHODS

This was a prospective observational case series. Physicians completed a data collection form after the propofol sedation. The physicians were asked to report physiologic changes that occurred during sedation and rate their satisfaction with propofol as a sedation agent on a 100-mm visual analog scale.

RESULTS

Eight hundred eighty-six sedation events were reported. The median initial dose of propofol given was 2.0 mg/kg and the median total dose was 3.6 mg/kg. Propofol was used for a wide range of procedures. The most common physiologic change was desaturation/hypoxia (desaturation to <90% in 7.2%). No deaths, unplanned intubations, or surgical airway placements were reported. Treating physicians reported a median satisfaction score of 97 mm.

CONCLUSIONS

A 2-mg/kg initial bolus dose of propofol for pediatric sedation was well tolerated and useful for a wide range of procedures. Physicians should expect to find a high level of satisfaction with this dose.

Procedural sedation for diagnostic imaging in children by pediatric hospitalists using propofol: analysis of the nature, frequency, and predictors of adverse events and interventions

OBJECTIVE

To evaluate the nature, frequency, and predictors of adverse events during the use of propofol by pediatric hospitalists.

STUDY DESIGN

We reviewed 1649 charts of patients sedated with propofol by pediatric hospitalists at St Louis Children's Hospital between January 2005 and September 2009.

RESULTS

Hospitalists were able to complete 1633 of the 1649 sedations reviewed (99%). Major complications included 2 patients with aspiration and 1 patient intubated to complete the study. We observed a 74% reduction in the number of patients with respiratory events and airway interventions from 2005 to 2009. Predictors of respiratory events were history of snoring (OR, 2.40; 95% CI, 1.52-3.80), American Society of Anesthesiologists (ASA) physical status classification of ASA 3 (OR, 2.30; 95% CI, 1.22-4.33), age >12 years (OR, 4.01; 95% CI, 2.02-7.98), premedication with midazolam (OR, 1.85; 95% CI, 1.15-2.98), and use of adjuvant glycopyrrolate (OR, 4.70; 95% CI, 2.35-9.40). All except ASA 3 status were also predictors for airway intervention. There was a decline in the prevalence of all of these predictors over the study years (P < .05) except for use of glycopyrrolate.

CONCLUSION

Our pediatric hospitalists implemented a successful propofol sedation program that realized a 74% reduction in respiratory events and airway interventions between 2005 and 2009. Decreased prevalence of the predictors of adverse events that we identified likely contributed to this reduction.

Pediatric procedural sedation and analgesia

Procedural sedation and analgesia (PSA) is an evolving field in pediatric emergency medicine. As new drugs breach the boundaries of anesthesia in the Pediatric Emergency Department, parents, patients, and physicians are finding new and more satisfactory methods of sedation. Short acting, rapid onset agents with little or no lingering effects and improved safety profiles are replacing archaic regimens. This article discusses the warning signs and areas of a patient's medical history that are particularly pertinent to procedural sedation and the drugs used. The necessary equipment is detailed to provide the groundwork for implementing safe sedation in children. It is important for practitioners to familiarize themselves with a select few of the PSA drugs, rather than the entire list of sedatives. Those agents most relevant to PSA in the pediatric emergency department are presented.

The 'dark' side of sedation: 12 years of office-based pediatric deep sedation for electroretinography in the dark

OBJECTIVES

Analyze pediatric ERG data for adverse events, interventions, and outcomes of propofol sedations performed in near-complete darkness.

AIM

To demonstrate that deep sedation with propofol for ERG can be performed efficiently and safely in children in near-total darkness.

BACKGROUND

Full-field electroretinography (ERG) is a valuable tool for the diagnosis of vision loss in children. The ERG measures the electrical activity of the retina. In children, ERG quality significantly improves with deep sedation by allowing easier eye electrode placement and decreasing motion artifacts. As this procedure must be performed in darkness, administering sedation imposes unique challenges.

METHODS AND MATERIALS

ERGs are performed outside of the operating room in our hospital's electrophysiology suite. IVs are placed, and patients are allowed to adapt to complete darkness. An anesthesiologist then administers propofol sedation in the dark with the aid of a red-filter light source and monitor light shields. Data were collected on 379 patients (411 ERGs) performed from 1996 to 2008. These records were reviewed and analyzed for demographic, medical, and anesthetic data.

RESULTS

Propofol sedation resulted in an ERG completion rate of 99.5%. During sedation, 8.5% (35) of patients experienced minor respiratory complications such as airway obstruction that resulted in an oxygen saturation <90%. A total of 9.7% (40) of patients required minor airway interventions such as a chin lift.

CONCLUSIONS

We demonstrated that pediatric sedation is a safe, efficient, and a cost-effective method for measuring ERGs in a challenging environment. The incidence of minor complications is low and appears similar to other studies of propofol sedation.

Professional skills and competence for safe and effective procedural sedation in children: recommendations based on a systematic review of the literature

Objectives. To investigate which skills and competence are imperative to assure optimal effectiveness and safety of procedural sedation (PS) in children and to analyze the underlying levels of evidence. Study Design and methods. Systematic review of literature published between 1993 and March 2009. Selected papers were classified according to their methodological quality and summarized in evidence-based conclusions. Next, conclusions were used to formulate recommendations. Results. Although the safety profiles vary among PS drugs, the possibility of potentially serious adverse events and the predictability of depth and duration of sedation define the imperative skills and competence necessary for a timely recognition and appropriate management. The level of effectiveness is mainly determined by the ability to apply titratable PS, including deep sedation using short-acting anesthetics for invasive procedures and nitrous oxide for minor painful procedures, and the implementation of non-pharmacological techniques. Conclusions. PS related safety and effectiveness are determined by the circumstances and professional skills rather than by specific pharmacologic characteristics. Evidence based recommendations regarding necessary skills and competence should be used to set up training programs and to define which professionals can and cannot be credentialed for PS in children.

Intravenous thiamylal and local anesthetic infiltration for pediatric facial repair procedures performed in emergency departments

Thiamylal is widely used for procedural sedation in emergency departments (ED); however, there are limited safety data for doses of thiamylal > 5 mg/kg in children. We investigated whether intravenous thiamylal in combination with local anesthetics is safe and effective for pediatric procedural sedation in the ED and to identify the association between increasing doses thiamylal and adverse events. Between July 2004 and June 2008, 227 children who underwent procedural sedation met the inclusion criteria, including 105 males (46.3%) and 122 females (53.7%). Facial laceration was the most common indication for procedural sedation. All children received an intravenous injection of thiamylal, with a loading dose of 5 mg/kg. Eighty-one children (35.7%) received a supplemental dose of 2.5 mg/kg thiamylal because of inadequate sedation. Of these, 27 (11.9%) received a second supplemental dose of 2.5 mg/kg because of inadequate sedation. Sixty-six patients (29.1%) experienced 75 mild and self-resolving adverse events, and most of which (15/75; 20%) were drowsiness. Four (1.8%) patients experienced oxygen saturation below 96%, which was related to the supplemental dose of thiamylal (p = 0.002). No children suffered from any lasting or potentially serious complications. Our results indicate that intravenous thiamylal in combination with local anesthetic infiltration is a well tolerated for therapeutic procedures in the ED. Thiamylal offers rapid onset of sedation without compromising the patient's cardiorespiratory function during pediatric procedural sedation.

Pediatric procedural sedation by a dedicated nonanesthesiology pediatric sedation service using propofol

OBJECTIVES

To evaluate the success and dosing requirements of propofol in children for prolonged procedural sedation by a nonanesthesiology-based sedation service.

METHODS

The pediatric sedation service at this institution uses propofol as its preferred sedative, and the local guideline suggests using 3 mg/kg for induction and 5 mg kg(-1) h(-1) for maintenance sedation. Doses can be adjusted as needed to individualize successful sedation. A retrospective analysis of patients sedated for 30 minutes or longer was conducted. Patients were stratified into 4 cohorts based on age (<1 year [n = 16], 1-2 years [n = 85], 3-7 years [n = 54], and >7 years [n = 55]) and dosing patterns, success, and adverse effects were investigated.

RESULTS

Two hundred forty-nine patients met the inclusion criteria. Mean age was 4.8 years (SD, 4.1). The mean induction dose was 3.2 mg/kg (range, 0.9-9.7), and the mean maintenance infusion was 5.2 mg kg(-1) h(-1) (range, 0.14-21.3). No differences were seen in the induction doses in the different age cohorts, yet the SD was largest in the youngest cohort compared to any other. Although no differences were seen in maintenance rates by age, the greatest SD for dosing was seen in the oldest cohort. For all ages, all sedations were successful (100%) and unanticipated adverse effects rare (<1%).

CONCLUSIONS

Although it seems that the mean dosing of propofol does not vary significantly with age, there is greater variability in induction dosage for those younger than 1 year and in maintenance dosing for those 7 years or older. The results and general dosing parameters may assist pediatric subspecialists in using propofol for prolonged procedural sedation.

Safety of procedural sedation and analgesia in children less than 2 years of age in a pediatric emergency department

BACKGROUND

Although young age is considered a risk factor for adverse events related to procedural sedation and analgesia (PSA), data in very young children (<2 years of age) are lacking.

AIMS

The main objective of our study is to describe PSA in children <2 years of age in an inner city tertiary care pediatric emergency department (PED).

METHODS

We conducted a retrospective chart review from January 2005 to June 2007 of children <2 years of age who received PSA in our PED. We collected demographic variables, indication for and medications used for PSA, adverse events (AE) related to PSA, and interventions performed to treat them.

RESULTS

Of the children who received PSA, 14.5% (180/1,235) were <2 years of age of whom 173 were included for the analysis; 73% (126/173) of the study subjects were between 1 and 2 years of age, 54.3% (94/173) were male, and 96.5% (167/173) belonged to American Society of Anesthesiologists class 1. Incision and drainage (45.0%, 78/173) and laceration repair (32.4%, 56/173) were the two most common indications for PSA. Ketamine and midazolam was the most common combination medication used for PSA (62.4%, 108/173). Sedation was deemed ineffective in 5.8% (10/173) of the children. There were only two failed sedations; 5.8% (10/173) of the children experienced AE with most being minor [oxygen desaturations 1.7% (3/173), emesis 2.3% (4/173), and others 1.2% (2/173)]. One child experienced serious AE in the form of apnea and bradycardia requiring intubation.

CONCLUSIONS

Our data suggest that children under 2 years of age can be sedated effectively without increased risk of AE in a PED.

Initiating a hospital-wide pediatric sedation service provided by emergency physicians

Advanced diagnostic procedures, imaging studies, and therapeutic procedures have combined to substantially increase the need for pediatric sedation. The objective of this study is to describe the initiation of a hospital-wide (nonemergency department) pediatric deep sedation service provided by pediatric emergency physicians. This article describes a consecutive cohort of pediatric patients undergoing deep sedation provided by a new hospital sedation service (excluding the emergency department). The results of 133 pediatric deep sedations are described. Propofol was used for most sedations. Mean infusion times were 55 minutes for MRI scans and 13 minutes for heme-oncology procedures. The risk of adverse events was low. This case series of pediatric deep sedation patients describes the initiation of a hospital-wide pediatric sedation service utilizing pediatric emergency physicians, which has resulted in improved patient care, and improved financial performance of several hospital units. The risk of adverse events is low if proper precautions are taken.

Ketamine-propofol combination sedation for fracture reduction in the pediatric emergency department

OBJECTIVES

To evaluate the time of onset and recovery from and the efficacy and safety of intravenous ketamine-propofol sedation for reduction of forearm fractures in the pediatric emergency department setting.

STUDY DESIGN

Prospective, observational pilot study.

METHODS

Children presenting to an urban pediatric emergency department requiring sedation for closed reduction of forearm fractures received ketamine 0.5 mg/kg and propofol 1 mg/kg. We measured time intervals from drug administration to reduction, recovery, and attainment of discharge criteria, and obtained ratings of depth of sedation, pain, and ease of reduction. A follow-up survey elicited patient recall, parental satisfaction, and delayed complications. Complications were recorded during the procedure and by chart review.

RESULTS

Reduction was successful in 19 of 20 patients with one requiring open reduction. Median time intervals measured from initiation of ketamine injection were 5 minutes to reduction completion, 10 minutes to first purposeful response, and 38 minutes to suitability for discharge. Three patients recalled reduction or casting, but in no case was reduction reported to be the most painful aspect of visit. Emergency physicians and orthopedic residents rated sedation and ease of reduction favorably. Complications included mild hypoxia, vomiting, and transient ataxia. No apnea, hemodynamic compromise, dysphoria, or injection pain occurred.

CONCLUSIONS

In this pilot study, the combination of ketamine and propofol provided effective sedation with rapid recovery and no clinically significant complications for children requiring closed reduction of forearm fractures.

The nature of anesthesia and procedural sedation outside of the operating room

PURPOSE OF REVIEW

Procedural sedation and monitored anesthesia care have become increasingly common in locations outside of the operating room. The different types of procedures are presented along with pertinent safety issues with the use of different drug combinations.

RECENT FINDINGS

Based on the annual data from one hospital, of approximately 63,000 patients undergoing diagnostic or therapeutic procedures under sedation or anesthesia, 41% were sedated by non-anesthesiologists. Monitored anesthesia care was given to 0.4% of patients outside of the operating room. Events associated with monitored anesthesia care have been related to age, American Society of Anesthesiologists physical status, and obesity. Without the use of capnography, significant delays in the detection of apnea were demonstrable. Respiratory compromise with propofol for sedation appears less than that described for sedation using opiates and benzodiazepines.

SUMMARY

The number and types of procedures done outside of the operating room are steadily increasing. Sedation for these is often provided by nonanesthesiologists. A quality assurance system dedicated to track events associated with procedural sedation and anesthesia done outside of the operating room is instrumental for the maintenance of exemplary quality of sedation and safety of our patients.

Comparison of propofol with pentobarbital/midazolam/fentanyl sedation for magnetic resonance imaging of the brain in children

OBJECTIVE

Propofol and pentobarbital, alone or combined with other agents, are frequently used to induce deep sedation in children for MRI. However, we are unaware of a previous comparison of these 2 agents as part of a randomized, controlled trial. We compared the recovery time of children after deep sedation with single-agent propofol with a pentobarbital-based regimen for MRI and considered additional variables of safety and efficacy.

METHODS

This prospective, randomized trial at a tertiary children's hospital enrolled 60 patients 1 to 17 years old who required intravenous sedation for elective cranial MRI. Patients were assigned randomly to receive a loading dose of propofol followed by continuous intravenous infusion of propofol or to receive sequential doses of midazolam, pentobarbital, and fentanyl until a modified Ramsay score of >4 was attained. A nurse who was blind to group assignment assessed discharge readiness (Aldrete score > 8) and administered a follow-up questionnaire. We compared recovery time, time to induction of sedation, total sedation time, quality of imaging, number of repeat-image sequences, adverse events, caregiver satisfaction, and time to return to presedation functional status.

RESULTS

The groups were similar in age, gender, race, American Society of Anesthesiology physical status class, and frequency of cognitive impairment. No sedation failure or significant adverse events were observed. Propofol offered significantly shorter sedation induction time, recovery time, total sedation time, and time to return to baseline functional status. Caregiver satisfaction scores were also significantly higher in the patients in the propofol group.

CONCLUSIONS

Propofol permits faster onset and recovery than, and comparable efficacy to, a pentobarbital/midazolam/fentanyl regimen for sedation of children for MRI.

Clinical Practice Advisory: Emergency Department Procedural Sedation With Propofol

We present an evidence-based clinical practice advisory for the administration of propofol for emergency department procedural sedation. We critically discuss indications, contraindications, personnel and monitoring requirements, dosing, coadministered medications, and patient recovery from propofol. Future research questions are considered.

Pediatric Procedural Sedation in the Community Emergency Department: results from the ProSCED registry

OBJECTIVES

Emergency department procedural sedation practices for children have been reported for pediatric tertiary care centers. This report describes these same practice patterns and outcomes for community hospital-based general emergency physicians (EPs) in their treatment of pediatric patients.

METHODS

The Procedural Sedation in the Community Emergency Department registry is a prospective observational database composed of consecutive EP-directed procedural sedation cases in community hospitals. Information on sedation cases is collected at the time of the patient encounter and entered into an Internet-accessed database.

RESULTS

A total of 1028 procedural sedations were performed on 977 patients at 14 study sites, with 341 procedures performed in 339 patients younger than 21 years. The most common specified pediatric procedures performed included laceration repairs (n = 86, 25%), shoulder relocations (n = 78, 23%), and fracture care of the upper extremity (n = 56, 16%). Medications used included ketamine (n = 141, 41%), midazolam (n = 10, 32%), etomidate (n = 54, 16%), fentanyl (n = 51, 15%), and propofol (n = 47, 14%). Complications were reported in 2 cases (0.6%), 1 episode of apnea requiring a reversal agent and 1 episode of hypoxia responsive to supplemental oxygen. Of procedures attempted, 339 (99.4%) were successfully completed. Emergency physicians both directed the sedation and performed the procedure in 252 cases (74%), whereas in another 69 cases (20%), they directed the sedation for another physician performing the procedure. In 20 cases (5.8%), the EP directed sedation for a painless diagnostic study.

CONCLUSIONS

Community EPs in the Procedural Sedation in the Community Emergency Department registry deliver safe and effective pediatric sedation using a broad selection of agents.

Procedural sedation in the community emergency department: initial results of the ProSCED registry

OBJECTIVES

Procedural sedation and analgesia (PSA) has been well profiled in experimental studies in university emergency departments. Extrapolation of these practices into the community hospital setting is not well established. This report describes community hospital practices and outcomes in a multicenter PSA registry.

METHODS

The Procedural Sedation in the Community Emergency Department (ProSCED) registry is a prospective observational database composed of consecutive emergency physician-directed procedural sedation cases in community hospitals. Registered procedures described by 15 categorical data fields are collected at the time of the patient encounter and entered into a secure Internet-housed database.

RESULTS

A total of 1,028 procedural sedations were performed on 980 patients at 14 study sites. The most common specified procedures performed included shoulder relocation (392), hip relocation (102), elbow relocation (70), upper extremity fracture care (69), lower extremity fracture care (66), and facial laceration repair (67). Complications of any description occurred in 42 cases (4.1%), with no patient's disposition changed secondary to a complication. Patients' ages ranged from 1 month to 95 years, with a median age of 31 years. Of procedures attempted, 982 (95.5%) were successfully completed, 21 cases (2.0%) were adequately sedated but unable to have their procedure completed, and 21 cases (2.0%) were believed to be inadequately sedated. Medication use included midazolam in 423 cases (41.1%), propofol in 253 (24.6%), fentanyl in 253 (24.6%), etomidate in 241 (23.4%), and ketamine in 145 (14.1%), as well as several others. Cases using either ketamine or propofol exhibited the fewest complications, while those using fentanyl, hydromorphone, or midazolam demonstrated the highest complication rates.

CONCLUSIONS

Community emergency physicians deliver safe and effective PSA over a wide variety of ages and procedures while using a broad selection of agents.

Intraindividual propofol dosage variability in children undergoing repetitive procedural sedations

The authors prospectively assessed intraindividual variability in propofol dosage for induction of sedation in repetitive procedures in children with malignancies. A total of 80 procedures were performed in 24 children. Primary outcome measure was the intraindividual propofol dose required to achieve adequate sedation. Intraindividual variability in propofol dosage required to achieve adequate sedation was 0.0-2.2 mg.kg-1. Twenty-five percent of the patients had a dose range of 0.0-0.5 mg x kg-1; 37.5%, >0.5-1.0 mg x kg-1; and 37.5% >1.0-2.2 mg x kg-1. Due to remarkable intraindividual differences, propofol dosage should be titrated toward the desired level of sedation.

Propofol by infusion protocol for ED procedural sedation

INTRODUCTION

Propofol is an effective agent for use in procedural sedation and analgesia (PSA). Most ED studies have used a bolus-dosed protocol. We evaluated the efficacy, complication rate, and satisfaction among caregivers and patients while using an infusion-dosed protocol of propofol for PSA in our ED.

METHODS

A prospective, observational study was performed in our academic ED. Propofol use was at the discretion of the ordering physician and dosed by predetermined infusion protocol. Variables measured included adverse events, times of sedation, procedure, and recovery. Patient and provider satisfaction were measured using a 10-cm visual analog scale.

RESULTS

Fifty patients were enrolled over 18 months. Procedures were varied, and all were successfully completed. The mean propofol dose was 174 mg (SD = 164 mg). Average times to sedation (4.6 minutes, SD = 2.6 minutes) and recovery (8.2 minutes, SD = 5.8 minutes) were short. Complications included 8 patients with respiratory depression and 6 with hypotension, all easily reversible. Satisfaction scores were uniformly high. Only 34% of patients had any memory of the procedure, and 94% would agree to use it again if necessary.

CONCLUSIONS

Infusion-dosed propofol is effective for ED PSA. Total doses, effectiveness, satisfaction rates, and complications of infusion-dosed propofol are comparable to findings from studies using bolus-dosed protocols.

Demographics and trends in nonoperating-room anesthesia

PURPOSE OF REVIEW

Nonoperating-room anesthesia includes sedation or anesthesia for radiological imaging, cardiac catheterization, office-based surgery, and pediatric procedures or investigations, all of which have seen explosive growth over the last decade. This review discusses the factors that are driving this growth and the challenges we face as a profession to accommodate new practice paradigms.

RECENT FINDINGS

Many departments have difficulty providing services for nonoperating-room anesthesia. A shortage of providers, insufficient reimbursement, and lack of institutional support have been identified as barriers limiting delivery of pediatric nonoperating-room sedation services. Practitioners from other specialties appear increasingly eager to provide sedation at an institutional level. The use of propofol by nonanesthesiologists is widespread, and the issue of provider credentialing has yet to be fully resolved. The shift to nonoperating-room locations will continue, driven by cost savings and convenience for patients and providers.

SUMMARY

Nonoperating-room anesthesia will play a central role in anesthesia practice in the future. Provision of these services requires planning, personnel, and institutional resources. This should be a high priority for anesthesiology departments to ensure delivery of the highest quality of patient care in a cost-effective and organized manner.

Pediatric sedation outside the operating room: the year in review

PURPOSE OF REVIEW

This review is a survey of the recent literature concerning issues and trends in the rapidly changing field of pediatric sedation.

RECENT FINDINGS

Clinical guidelines for the safe provision of sedation to children continue to be developed and revised. Systems for providing sedation are evolving, and the most successful models emerging are those that involve a dedicated team, either mobile or stationary, of physicians and nurses. A variety of drugs is used, and potent drugs that were designed as anesthetics, such as propofol and ketamine, are being administered outside the operating room by anesthesiologists and non-anesthesiologists. The safety of this practice continues to be debated. The reported incidence of adverse events is different in various settings and systems; however, outcome data are difficult to compare because of differences in study design and outcome definition. There is agreement that sedation is a continuum, and evidence that the depth of sedation attained during procedural sedation in children is often consistent with general anesthesia. Capnography and processed electroencephalogram monitoring have been described in sedation studies, may enhance safety during pediatric sedation, and should be investigated further.

SUMMARY

The evolution of systems, drugs, and monitors for the provision of pediatric sedation is continuing. An accurate assessment of safety and other outcomes will be enhanced through the establishment of multicenter collaborative databases.

Pediatric procedural sedation and analgesia

Children often present with painful conditions that require painful interventions. Procedural sedation and analgesia refers to the pharmacologic technique of managing a child's pain and anxiety. Procedural sedation is a safe, effective, and humane way to facilitate appropriate medical care. It is important to distinguish the goals for the procedural sedation, pain relief or anxiolysis or both. Different medications and combinations of medications can be used to achieve the desired effect. It is also important to keep in mind the possible adverse reactions and side effects associated with each medication when choosing the sedation cocktail.

A review of the use of propofol for procedural sedation in the emergency department

Sedation for short but potentially painful procedures is often undertaken in the emergency department. The ideal sedative regimen should provide analgesia and anxiolysis with minimal side effects and cardiorespiratory depression and rapid recovery post-procedure. Propofol has found increasing popularity with anaesthetists for sedation in the operating theatre. This is a review of the current literature looking at the use of propofol for procedural sedation in the emergency department. A comprehensive literature search of Medline from 1966 to week 4 of 2005, Embase from 1980 to week 10 of 2005, and the Cochrane Library was carried out using the OVID interface. Eight articles were selected for review. The evidence suggests that propofol is both effective and safe to use in the emergency department. However, several of the papers reviewed used deep levels of sedation that are not recommended in the UK by non-anaesthetists.

Propofol anesthesia in spontaneously breathing children undergoing magnetic resonance imaging: comparison of two propofol emulsions

BACKGROUND

This study evaluated a propofol-based anesthesia regimen with spontaneous breathing in pediatric patients scheduled for magnetic resonance imaging (MRI).

METHODS

In this prospective, randomized, double-blind study propofol formulated with long-chain triglycerides (LCT) and mixed medium-chain/long-chain triglycerides (MCT/LCT) were used. Ninety patients aged 2.4 months to 7.3 years were premedicated with intravenous midazolam. Lidocaine was injected prior to propofol to reduce injection pain. Anesthesia was induced and maintained by propofol. Glycopyrronium bromide was administered for saliva reduction. Hemodynamics, blood oxygen saturation and endtidal capnography were continuously monitored. All patients received additional oxygen. The aggregated propofol dose for induction and maintenance of anesthesia was analyzed for therapeutic equivalence. Incidence of injection pain, laboratory safety values, vital signs, and the adverse event profile were analyzed to compare tolerability and safety.

RESULTS

Propofol anesthesia was safe and successful in all children. Both propofol formulations were equivalent regarding dose requirements (mean induction and maintenance doses for anesthesia 2.0-4.0 mg.kg(-1) and 6.0-8.8 mg.kg(-1).h(-1) respectively; aggregated doses 8-13.26 mg.kg(-1)). There were no differences in drug safety such as hemodynamics, spontaneous breathing, injection pain, and laboratory values. Duration of induction and of recovery from anesthesia were short and all examinations were completed with minimal interruption.

CONCLUSIONS

Propofol-based short-term anesthesia was well suited for anesthesia during MRI procedures in the studied pediatric patients. There were no clinically relevant differences between the two propofol formulations.

Propofol for emergency department procedural sedation and analgesia: a tale of three centers

OBJECTIVES

To characterize propofol procedural sedation and analgesia (PSA) encounters for a large patient population at multiple emergency department (ED) sites. The authors sought to assess the frequency of respiratory and cardiovascular events during propofol PSA within these settings.

METHODS

This study was a prospective, descriptive series of a consecutive sample of ED patients receiving propofol for PSA at three study sites. Patients were monitored for PSA-related events, including predefined clinically relevant cardiovascular and respiratory events. Data collection was performed during PSA with a standardized data collection sheet unique to each site.

RESULTS

Propofol was administered during PSA to 792 patients during the respective reporting period at each center. Indications for sedation included dislocation reduction (38%), cardioversion (10%), fracture reduction (35%), abscess incision and drainage (8%), computed tomography imaging (2%), and tube thoracostomy (1%). The cumulative rate of oxygen desaturation events for all study sites was 7.7% with a brief period of assisted ventilation with bag-valve mask in 3.9%. The cumulative rate of PSA-related hypotensive events was 3.5%. Increasing patient age and specific clinical procedure were clinical variables most associated with any propofol-related respiratory event. All PSA-related events resolved with supportive interventions during the PSA encounter. No patients required endotracheal intubation, prolonged observation, or admission for PSA-related complications.

CONCLUSIONS

Propofol typically confers a deep sedation experience for ED PSA. The most common PSA events associated with propofol are respiratory related and appear consistent across these three practice settings. All propofol-related PSA events resolved with brief supportive interventions in the ED with no adverse sequelae.