Procedural sedation and analgesia in the emergency department. Canadian Consensus Guidelines

Procedural sedation in the emergency department by Italian emergency physicians: results of the SEED SIMEU registry

BACKGROUND AND IMPORTANCE

Effective and safe procedural sedation is pivotal for the quality of care in the emergency department (ED).

OBJECTIVES

The aim of this work is to evaluate the feasibility, effectiveness, and safety procedural sedation performed by emergency physicians in the ED setting in Italy.

DESIGN/SETTING AND PARTICIPANTS/INTERVENTION

Following a specific training of the staff and with the adoption of a standardized protocol, a registry of procedural sedations performed on adult patients in 10 Italian EDs was compiled from 2019 to 2022; the following basic data were recorded: demographic and clinical information, procedure's indication, administered drugs, predefined, and actual sedation level.

OUTCOME MEASURES AND ANALYSIS

Effectiveness was evaluated considering three parameters: successful completion of the procedure, absence of procedural pain, and no memory of the procedure; adverse events were classified according to the World Society of Intravenous Anaesthesia criteria and evaluated taking into account clinical and procedural variables.

MAIN RESULTS

The study included 1349 patients (median age 68 years, male 64%). Sedation was performed for electrical cardioversion (66.3%), orthopedic procedures (23.2%), or other procedures (10.5%). Propofol (67%) and midazolam (24.2%) were the two most frequently used sedatives and 70.6% of the patients achieved a deep level of sedation.Procedural failure occurred in 4.6% of cases, with no significant differences between procedure types or drugs used. Recall of the procedure and procedural related pain were reported by 2.9% and 2.6% of patients, respectively, and were more frequently related to orthopedic procedures, midazolam use - if compared with propofol, and lower levels of sedation.A total of 135 adverse events were observed, with an overall incidence of 10%: 38 minimal adverse events (2.8%), 38 minor adverse events (2.8%), and 59 moderate adverse events (4.4%). There were no adverse events requiring unplanned hospital admission or escalation of care, and no sentinel adverse events were observed. All adverse events were resolved with simple and noninvasive treatments. The incidence of adverse events was greater with higher American Society of Anesthesiologists class, intermediate/difficult airway, and deeper sedation levels.

CONCLUSION

Procedural sedation performed in Italian EDs by emergency physicians, with propofol as main sedative, was effective and safe, and has comparable adverse event rates with previous international studies.

Assessment of the practice of pediatrics procedural sedation and analgesia for magnetic resonance imaging and computed tomography scan at a teaching hospital, Ethiopia, 2020: A clinical audit

BACKGROUND

The main goals of paediatric sedation/general anesthesia vary according to the specific imaging procedure, but generally includes anxiety relief, pain control and control of excessive movement. The quality of magnetic resonance imaging (MRI) and computed tomography (CT) depends largely on immobility of the patient during the procedure, which is often difficult to achieve without sedation in children. Sedation is the depression of the central nervous system and reflexes by the administration of drugs. Brain imaging is routinely used to identify stroke, hemorrhage, and structural abnormalities. All patients undergoing procedural sedation and those receiving general anesthesia should be evaluated equally.

AIM

The study aimed to perform a clinical audit of sedation and analgesia practices for magnetic resonance imaging and computed tomography compared against the guidelines/standards to determine if practice meets the standards and identify areas of non-compliance at a teaching Referral Hospital in Ethiopia.

METHODS

This clinical audit was conducted from January 1 to May 30/2020 for 5 months at a teaching Referral Hospital in Ethiopia. All children below the age of 6 years underwent MRI and CT imaging procedures under sedation during a study period were included. Data were collected through direct observation using checklists of standards by a trained data collector. Descriptive statistics were presented with tables, graphs of sums and percentages of items using SPSS version 20.

RESULTS

A total of 40 children underwent MRI and CT imaging were observed at the Hospital imaging sites. Among the 20 standards, 6 of them had 100% compliance rate, 3 of the standards had 0% complaince rate and 11 of the standards had the compliance rate of between 0 and 100%.

CONCLUSIONS AND RECOMMENDATIONS

In general, even though the practice guidelines of procedural sedation for MRI and CT recommend to practice procedures based on the standards, this study showed there were a number of standards that had <100% compliance rate. Therefore, it is recommended that staff should adopt standards or locally prepared protocols for their day-to-day practice.

A mini-review of procedural sedation and analgesia in the emergency department

Procedural sedation and analgesia (PSA) is performed for a variety of indications in emergency departments (EDs). Although the practice of PSA in the ED is somewhat unique from other clinical areas, there is currently no guideline for this practice in Japan. Policy statements and guidelines for PSA have been published in Europe and North America. These guidelines suggest first evaluating patients carefully before performing PSA, and then deciding on target sedative level and choice of medications. Patient evaluation requires a combination of continuous visual observation by trained medical staff to assess the depth of sedation and respiration with noninvasive measurements of blood pressure, continuous electrocardiography monitoring, and pulse oximetry. Sedative selection should be based on its characteristics, peak time, effectiveness, and risks. It is important to administer sedatives and analgesics in small, incremental doses while keeping a close eye on the patient’s reaction to avoid adverse events (AEs) until the planned sedation level is reached. Further, additional attention is needed for special populations such as pediatric and elderly patients. PSA is a key element for patient‐centered care in emergency medicine. In this manuscript, we review the available evidence for PSA in the EDs, including guidelines for evaluation, monitoring, pharmacology, AEs, and special populations such as pediatric and elderly patients.

Comparison of the efficacy of ketamine- propofol versus sodium thiopental-fentanyl in sedation: a randomised clinical trial

BACKGROUND

Many sedative regimens have been studied with controversial efficiencies. This study tried to assess the desirable and adverse effects of sodium thiopental-fentanyl (TF) with ketamine-propofol (KP) for procedural sedation and analgesia in the emergency department.

METHODS

After signing written consent, patients were enrolled in this randomised double-blind trial to receive either KP or TF to reach the desired sedation level. The respiratory and haemodynamic complications, nausea and vomiting, recovery agitation, patient recall and satisfaction, provider satisfaction and recovery time were compared.

RESULTS

Of the participants, 47 in the KP group and 49 in the TF group were enrolled. The mean and SD scores were 6.91±1.93 and 8.34±1.25 for patients' satisfaction and 7.55±1.54 and 8.65±1.00 for satisfaction of physicians performing the procedures in TF and KP groups, respectively (p=0.000). Moreover, 39 (79.59%) and 18 (38.29%) of patients declared that they had recalled the procedures in the TF and KP groups, respectively (p=0.000). Transient hypoxia was reported in 2.1% and 8.1% in the KP and TF groups leading to perform 4.2% vs 8.1% airway manoeuvres, respectively, without the need for endotracheal intubation or further admission.

CONCLUSIONS

KP and TF combinations were effectively comparable although KP resulted in higher patient and provider satisfaction. This study did not detect a difference regarding adverse respiratory or haemodynamic effects. It is estimated that the TF combination can be potent and efficacious with possible low adverse events in procedural sedation.

Opioid Use and Misuse Three Months After Emergency Department Visit for Acute Pain

BACKGROUND

Studies evaluating long-term prescription opioid use are retrospective and based on filled opioid prescriptions from governmental databases. These studies cannot evaluate if opioids were really consumed and are unable to differentiate if they were used for a new pain or chronic pain or were misused. The aim of this study was to assess opioid use rate and reasons for consuming 3 months after being discharged from the emergency department (ED) with an opioid prescription.

METHODS

This is a prospective cohort study conducted in the ED of a tertiary care urban center with a convenience sample of discharged patients ≥ 18 years who consulted for an acute pain condition (≤2 weeks). Three months post-ED visit, participants were interviewed by phone on their past 2-week opioid consumption and their reasons for consuming: a) for pain related to the initial ED visit, b) for a new unrelated pain, or c) for another reason.

RESULTS

Of the 524 participants questioned at 3 months (mean ± SD age = 51 ± 16 years, 47% women), 47 patients (9%, 95% confidence interval [CI] = 7%-12%) reported consuming opioids in the previous 2 weeks. Among those, 34 (72%) reported using opioids for their initial pain, nine (19%) for a new unrelated pain and four (9%) for another reason (0.8%, 95% CI = 0.3%-2.0%, of the whole cohort). Patients who used opioids during the 2 weeks after the ED visit were 3.8 (95% CI = 1.2-12.7) times more likely to consume opioids at 3 months.

CONCLUSION

Opioid use at the 3-month follow-up in ED patients discharged with an opioid prescription for an acute pain condition is not necessarily associated with opioid misuse; 91% of those patients consumed opioids to treat pain. Of the whole cohort, less than 1% reported using opioids for reasons other than pain. The rate of long-term opioid use reported by prescription-filling database studies should not be viewed as a proxy for incidence of opioid misuse.

Procedural sedation and analgesia practices in the emergency centre

Introduction

Procedural sedation and analgesia allows the clinician to safely and efficiently administer sedation, analgesia, anxiolysis and sometimes amnesia to facilitate the performance of various procedures in the emergency centre. The aim of this study is to determine current sedation practices, common indications and major obstacles in selected emergency centres across Southern Gauteng, South Africa, with a view to improving future standards and practices.

Methods

This was a prospective, questionnaire based, cross-sectional interview of emergency centre managers or their designee of selected private-sector and public-sector hospitals in Southern Gauteng.

Results

Overall, 17 hospitals completed the interview, nine (53%) public-sector and eight (47%) private-sector hospitals, with 36% of hospitals being aligned to an academic institute. All hospitals performed procedural sedation in their emergency centre. Forty seven percent of managers had between ten and 19 years of clinical experience post internship. Although eleven (64.7%) managers achieved a postgraduate qualification in emergency medicine, only seven (41%) were accredited with a Fellowship of the College of Emergency Medicine (FCEM) qualification and only three (17.7%) centres employed three or more specialists. The majority of centres (52.3%) performed between ten and 30 procedures per month requiring sedation. Staff training in the practice of procedural sedation was mostly obtained internally (52.9%), from in-house seniors. Essential drugs, procedure monitors, resuscitation equipment and protocols were all available in 70.6% of centres.

Conclusion

Although the safe practice and awareness of procedural sedation and analgesia in both public-sector and private-sector emergency centres in Southern Gauteng appears to be on the increase, there is still a need to enhance practitioner training and promote awareness of current local and international trends, protocols and recommendations.

Procedural sedation and analgesia in the emergency department in Japan: interim analysis of multicenter prospective observational study

PURPOSE

Procedural sedation and analgesia (PSA) is widely performed outside of the operating theater, often in emergency departments (EDs). The practice and safety of PSA in the ED in an aging society such as in Japan have not been well described. We aimed to characterize the practice pattern of PSA including indications, pharmacology and incidence of adverse events (AEs) in Japan.

METHODS

We formed the Japanese Procedural Sedation and Analgesia Registry, a multicenter prospective observation registry of ED patients undergoing PSA. We included all patients who received PSA in the ED. PSA was defined as any systemic pharmacological intervention intended to facilitate a painful or uncomfortable procedure. The main variables in this study were patients' demographics, American Society of Anesthesiologists (ASA) physical status, indication of PSA, medication choices, and AEs. The primary outcome measure was overall AEs from PSA.

RESULTS

We enrolled 332 patients in four EDs during the 12-month period. The median age was 67 years (IQR, 46-78). In terms of ASA physical status, 79 (23.8%), 172 (51.8%), and 81 (24.4%) patients were class 1, 2, 3 or higher, respectively. The most common indication was cardioversion (44.0%). The most common sedative used was thiopental (38.9%), followed by midazolam (34.0%) and propofol (19.6%). Among all patients, 72 (21.7%, 95% confidence interval, 17-26) patients experienced one or more AEs. The most common AE was hypoxia (9.9%), followed by apnea (7.2%) and hypotension (3.5%). All of the AEs were transient and no patient had a serious AE.

CONCLUSION

In a multicenter prospective registry in Japan, PSA in the ED appears safe particularly since the patients who underwent PSA were older and had a higher risk profile compared to patients in previous studies in different countries.

Comparison of nalbuphine and sufentanil for colonoscopy: A randomized controlled trial

OBJECTIVES

Nalbuphine is as effective as morphine as a perioperative analgesic but has not been compared directly with sufentanil in clinical trials. The aims of this study were to compare the efficacy and safety of nalbuphine with that of sufentanil in patients undergoing colonoscopy and to determine the optimal doses of nalbuphine in this indication.

METHODS

Two hundred and forty consecutive eligible patients aged 18-65 years with an American Society of Anesthesiologists classification of I-II and scheduled for colonoscopy were randomly allocated to receive sufentanil 0.1 μg/kg (group S), nalbuphine 0.1 mg/kg (group N1), nalbuphine 0.15 mg/kg (group N2), or nalbuphine 0.2 mg/kg (group N3). Baseline vital signs were recorded before the procedure. The four groups were monitored for propofol sedation using the bispectral index, and pain relief was assessed using the Visual Analog Scale and the modified Behavioral Pain Scale for non-intubated patients. The incidences of respiratory depression during endoscopy, nausea, vomiting, drowsiness, and abdominal distention were recorded in the post anesthesia care unit and in the first and second 24-hour periods after colonoscopy.

RESULTS

There was no significant difference in analgesia between the sufentanil group and the nalbuphine groups (p>0.05). Respiratory depression was significantly more common in group S than in groups N1 and N2 (p<0.05). The incidence of nausea was significantly higher in the nalbuphine groups than in the sufentanil group in the first 24 hours after colonoscopy (p<0.05).

CONCLUSIONS

Nalbuphine can be considered as a reasonable alternative to sufentanil in patients undergoing colonoscopy. Doses in the range of 0.1-0.2 mg/kg are recommended. The decreased risks of respiratory depression and apnea make nalbuphine suitable for patients with respiratory problems.

Between- and within-site variation in medication choices and adverse events during procedural sedation for electrical cardioversion of atrial fibrillation and flutter

OBJECTIVES

Although procedural sedation for cardioversion is a common event in emergency departments (EDs), there is limited evidence surrounding medication choices. We sought to evaluate geographic and temporal variation in sedative choice at multiple Canadian sites, and to estimate the risk of adverse events due to sedative choice.

METHODS

This is a secondary analysis of one health records review, the Recent Onset Atrial Fibrillation or Flutter-0 (RAFF-0 [n=420, 2008]) and one prospective cohort study, the Recent Onset Atrial Fibrillation or Flutter-1 (RAFF-1 [n=565, 2010 - 2012]) at eight and six Canadian EDs, respectively. Sedative choices within and among EDs were quantified, and the risk of adverse events was examined with adjusted and unadjusted comparisons of sedative regimes.

RESULTS

In RAFF-0 and RAFF-1, the combination of propofol and fentanyl was most popular (63.8% and 52.7%) followed by propofol alone (27.9% and 37.3%). There were substantially more adverse events in the RAFF-0 data set (13.5%) versus RAFF-1 (3.3%). In both data sets, the combination of propofol/fentanyl was not associated with increased adverse event risk compared to propofol alone.

CONCLUSION

There is marked variability in procedural sedation medication choice for a direct current cardioversion in Canadian EDs, with increased use of propofol alone as a sedation agent over time. The risk of adverse events from procedural sedation during cardioversion is low but not insignificant. We did not identify an increased risk of adverse events with the addition of fentanyl as an adjunctive analgesic to propofol.

Predicting morphine related side effects in the ED: An international cohort study

STUDY OBJECTIVES

Morphine is the reference treatment for severe acute pain in an emergency department. The purpose of this study was to describe and analyse opioid-related ADRs (adverse drug reactions) in a large cohort of emergency department patients, and to identify predictive factors for those ADRs.

METHODS

In this prospective, observational, pharmaco-epidemiological international cohort study, all patients aged 18years or older who were treated with morphine were enrolled. The study was done in 23 emergency departments in the US and France. Baseline numerical rating scale score and initial and total doses of morphine titration were recorded. Logistic regression analysis was used to study the effects of demographic, clinical and medical history covariates on the occurrence of opioid-induced ADRs within 6h after treatment.

RESULTS

A total of 1128 patients were included over 10months. Median baseline initial pain scores were 8/10 (7-10) versus 3/10 (1-4) after morphine administration. Median titration duration was 10min (IQR, 1-30). The occurrence of opioid-induced ADRs was 25% and 2% were serious. Patients experienced mainly nausea and drowsiness. Medical history of travel sickness (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.01-2.86) and history of nausea or vomiting post morphine (OR, 3.86; 95% CI, 2.29-6.51) were independent predictors of morphine related ADRs.

CONCLUSION

Serious morphine related ADRs are rare and unpredictable. Prophylactic antiemetic therapy could be proposed to patients with history of travel sickness and history of nausea or vomiting in a postoperative setting or after morphine administration.

Analgesic effect of paracetamol combined with low-dose morphine versus morphine alone on patients with biliary colic: a double blind, randomized controlled trial

BACKGROUND

Numerous drugs have been proposed to alleviate pain in patients with biliary colic, especially opioids, but still there is a tendency to use less narcotics because of their side effects and the unwillingness of some patients. The present study aimed to compare the analgesic effect of paracetamol combined with low-dose morphine versus morphine alone in patients with biliary colic.

METHODS

A randomized double-blind controlled trial was performed in 98 patients with biliary colic, recruited from two emergency departments from August 2012 to August 2013. Eleven patients were excluded and the remaining were randomized into two groups: group A received 0.05 mg/kg morphine+1 000 mg paracetamol in 100 mL normal saline and group B received 0.1 mg/kg morphine+normal saline (100 mL) as placebo. Pain scores were recorded using visual analogue scale (VAS) at baseline and 15 and 30 minutes after drug administration. Adverse effects and the need for rescue medication (0.75 µg/kg intravenous fentanyl) were also reported within 60 minutes of drug administration.

RESULTS

Before the infusion, the mean±SD VAS scores were 8.73±1.57 in group A and 8.53±1.99 in group B. At 15 minutes after drug administration, the mean±SD VAS scores were 2.16±1.90 in group A vs. 2.51±1.86 in group B; mean difference was -0.35, and 95%CI -1.15 to 0.45 (P=0.38). At 30 minutes the mean±SD VAS scores were 1.66±1.59 in group A vs. 2.14±1.79 in group B; mean difference was -0.48, and 95%CI -1.20 to 0.24 (P=0.19). The mean pain scores in the two groups at 15 and 30 minutes demonstrated no significant difference.

CONCLUSION

Paracetamol combined with low-dose morphine may be effective for pain management in patients with biliary colic.

Impact of age, sex and route of administration on adverse events after opioid treatment in the emergency department: a retrospective study

Opioids are an important avenue for the treatment of pain among individuals presenting to the emergency department. Unfortunately, opioid administration can lead to several complications including nausea/vomiting, oxygen desaturation and hypotension. The authors aimed to determine the incidence of such adverse events among 31,742 patients who were treated with opioids in the emergency department of a single large tertiary care hospital in Montreal, Quebec.

BACKGROUND:

The efficacy of opioids for acute pain relief in the emergency department (ED) is well recognized, but treatment with opioids is associated with adverse events ranging from minor discomforts to life-threatening events.

OBJECTIVE:

To assess the impact of age, sex and route of administration on the incidence of adverse events due to opioid administration in the ED.

METHODS:

Real-time archived data were analyzed retrospectively in a tertiary care urban hospital. All consecutive patients (≥16 years of age) who were assigned to an ED bed and received an opioid between March 2008 and December 2012 were included. Adverse events were defined as: nausea/vomiting (minor); systolic blood pressure (SBP) <90 mmHg, oxygen saturation (Sat) <92% and respiration rate <10 breaths/min (major) within 2 h of the first opioid doses.

RESULTS:

In the study period, 31,742 patients were treated with opioids. The mean (± SD) age was 55.8±20.5 years, and 53% were female. The overall incidence of adverse events was 12.0% (95% CI 11.6% to 12.4%): 5.9% (95% CI 5.6% to 6.2%) experienced nausea/vomiting, 2.4% (95% CI 2.2% to 2.6%) SBP <90 mmHg, 4.7% (95% CI 4.5% to 4.9%) Sat that dropped to <92% and 0.09% respiration rate <10 breaths/min. After controlling for confounding factors, these adverse events were associated with: female sex (more nausea/vomiting, more SBP <90 mmHg, less Sat <92%); age ≥65 years (less nausea/vomiting, more SBP <90 mmHg, more Sat <92%); and route of administration (intravenous > subcutaneous > oral).

CONCLUSIONS:

The incidence of adverse events associated with opioid administration in the ED is generally low and is associated with age, sex and route of administration.

Propofol-Based Procedural Sedation with or without Low-Dose Ketamine in Children

Objective Examine comparative dosing, efficacy, and safety of propofol alone or with an initial, subdissociative dose of ketamine approach for deep sedation. Background Propofol is a sedative-hypnotic agent used increasingly in children for deep sedation. As a nonanalgesic agent, use in procedures (e.g., bone marrow biopsies/aspirations, renal biopsies) is debated. Our intensivist procedural sedation team sedates using one of two protocols: propofol-only (P-O) approach or age-adjusted dose of 0.25 or 0.5 mg/kg intravenous ketamine (K + P) prior to propofol. With either approach, an initial induction dose of 1 mg/kg propofol is recommended and then intermittent dosing throughout the procedure to achieve adequate sedation to safely and effectively perform the procedure. Approach: Retrospective evaluation of 754 patients receiving either the P-O or K + P approach to sedation. Results A total of 372 P-O group patients and 382 K + P group. Mean age (7.3 ± 5.5 years for P-O; 7.3 ± 5.4 years for K + P) and weight (30.09 ± 23.18 kg for P-O; 30.14 ± 24.45 kg for K + P) were similar in both groups (p = NS). All patients successfully completed procedures with a 16% combined incidence of hypoxia (SPO2 < 90%). Procedure time was 3 minutes longer for K + P group than P-O group (18.68 ± 15.13 minutes for K + P; 15.11 ± 12.77 minutes for P-O; p < 0.01), yet recovery times were 5 minutes shorter (17.04 ± 9.36 minutes for K + P; 22.17 ± 12.84 minutes for P-O; p < 0.01). Mean total dose of propofol was significantly greater in P-O than in K + P group (0.28 ± 0.20 mg/kg/min for K + P; 0.40 ± 0.26 mg/kg/min for P-O; p < 0.0001), and might explain the shorter recovery time. Conclusion Both sedation approaches proved to be well tolerated and equally effective. Addition of ketamine was associated with reduction in the recovery time, probably explained by the statistically significant decrease in the propofol dose.

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.

Is propofol an optimal agent for procedural sedation and rapid sequence intubation in the emergency department?

Objective:

We conducted a qualitative systematic review to evaluate the efficacy and safety of propofol for direct current cardioversion (DCC), rapid sequence intubation (RSI) and procedural sedation in adult emergency department (ED) patients.

Data source:

MEDLINE (1966 to September 2000), PubMed (to September 2000), EMBASE (1988 to September 2000), Database of Systematic Reviews (to September 2000), Best Evidence (1991 to September 2000) and Current Contents (1996 to September 2000) databases.

Study selection:

English-language, randomized, comparative evaluations of propofol for procedures routinely conducted in adults (&gt;18 years) were included. Direct current cardioversion, RSI and procedural sedation were considered.

Data extraction:

Efficacy and safety endpoints were evaluated for all trials. For DCC and procedural sedation trials, efficacy measures included induction and recovery times, as well as the association for successful procedure. For the RSI trials, optimal intubating conditions were evaluated as the primary efficacy endpoint. Safety measures included hemodynamic changes, apnea rates and adverse effects.

Data synthesis:

In the setting of DCC, efficacy and safety outcomes were similar for propofol, thiopental, etomidate and methohexital. All of these agents provided markedly shorter induction and recovery times than midazolam. Patients who were pre-medicated with fentanyl exhibited prolonged recovery times and greater decreases in blood pressure. When used for RSI, propofol administration was associated with satisfactory intubating conditions that were comparable to those seen with thiopental and etomidate. Blood pressure reductions were seen in both DCC and RSI studies. Apneic episodes (&gt;30 seconds) occurred in 23% of propofol recipients, 28% of thiopental recipients and 7% of etomidate and midazolam recipients. Apart from the DCC studies described, no procedural sedation studies met our predefined review eligibility criteria.

Conclusion:

The body of literature evaluating propofol for DCC and RSI in the ED is limited. There is evidence to support the use of propofol for DCC and RSI, but this evidence comes from stable patients in non-ED settings. Further ED-based randomized comparative trials should be conducted before propofol is adopted for widespread use in the ED.

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.

Assessing, monitoring and managing continuous intravenous sedation for critically ill adult patients and implications for emergency nursing practice: A systematic literature review

BACKGROUND

Critically ill mechanically ventilated patients in ED have complex needs; chief among these is adequate sedation in addition to effective pain-relief. Emergency nurses are increasingly responsible sedation and analgesia for this complex cohort of patients. The aim of this review was to examine (1) the evidence around assessing, monitoring and managing continuous intravenous sedation for critically ill adult patients, and (2) the implications for emergency nursing practice.

STUDY DESIGN

Systematic review.

METHOD

The review of literature extended from 1946 to 2013 and examined peer review journal articles, policy and guidelines to provide a more complex understanding of a phenomenon of concern. A total of 98 articles were incorporated and comprehensively examined.

RESULTS

Analysis of the literature identified several implications for emergency nursing practice and the management of continuous intravenous sedation: workload, education, monitoring and assessing sedation and policy.

CONCLUSION

Limited literature was found that directly addressed Australasian emergency nursing practices' in managing on-going intravenous sedation and analgesia for patients. Balancing patient sedation and analgesia requires highly complex knowledge, skills and expertise; the degree of education and training required is above that obtained during pre-registration nurse training. No state or national models of education or training were identified to support ED nurses' practices in managing sedation. Little research has addressed the safety of continuous sedation use in ED.

Emergency nurses practices in assessing and administering continuous intravenous sedation for critically ill adult patients: a retrospective record review'

AIM

To generate an initial profile of emergency nurses' practices in and factors influencing the assessment and administration of continuous intravenous sedation and analgesia for critically ill mechanically ventilated adult patients.

BACKGROUND

Emergency nurses are relied upon to assess and manage critically ill patients, some of whom require continuous intravenous sedation. Balancing sedation is a highly complex activity. There is however little evidence relating to how emergency nurses manage continuous intravenous analgesia and sedation for the critically ill intubated patients.

DESIGN

Descriptive study.

METHOD

A 12-month retrospective medical record review was undertaken from January to December 2009 of patients (>16 years) administered continuous intravenous sedation in ED.

RESULTS

Fifty-five patients received ongoing intravenous sedation within the ED during a median length of stay of 3.4 h. Assessment of patient depth/quality of sedation and pain-relief varied and were rarely documented. Adverse events were documented, majority (16%) drug administration related. Thematic analysis identified three themes: 'Maintaining sedation', 'Directionless-directions', and 'Navigating the balance'.

CONCLUSION

Emergency nurses provide continuity of patient care and optimisation of analgesia and sedation for critically ill sedated patients. The safety and effectiveness of continuous intravenous sedation for the critically ill adult patient in ED are dependent on the expertise and decision-making abilities of the nurse.

A comparison of ketamine-midazolam and ketamine-propofol combinations used for sedation in the endobronchial ultrasound-guided transbronchial needle aspiration: a prospective, single-blind, randomized study

OBJECTIVE

We aimed to compare the effectiveness and safety of ketamine-midazolam and ketamine-propofol combinations for procedural sedation in endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA).

METHODS

Sixty patients who were undergoing EBUS-TBNA were included in this study. Patients were randomly divided into two groups. Group 1 was given 0.25 mg/kg intravenous (iv) ketamine, 2 min later than 0.05 mg/kg iv midazolam. Group 2 received 0.125 mg/kg ketamine-propofol mixture (ketofol), 2 min subsequent to injection of 0.25 mg/kg each. Sedation was maintained with additional doses of ketamine 0.25 mg/kg, and ketofol 0.125 mg/kg each in Group 1 and Group 2, respectively. Blood pressure, heart rate (HR), peripheral oxygen saturation, respiratory rate (RR), Ramsay Sedation Score (RSS), and severity of cough were recorded prior to and after administration of sedation agent in the beginning of fiberoptic bronchoscopy (FOB) and every 5 min of the procedure. The consumption of the agents, the satisfactions of the bronchoscopist and the patients, and the recovery time were also recorded.

RESULTS

HR in the 10(th) min and RSS value in the 35(th) min of induction in Group 1 were higher than the other group (P<0.05). The recovery time in Group 1 was statistically longer than Group 2 (P<0.05). There was no statistically significant difference between groups with respect to other parameters (P>0.05).

CONCLUSIONS

It was concluded that both ketamine-midazolam and ketamine-propofol combinations for sedation during EBUS-TBNA were similarly effective and safe without remarkable side effects.

Does midazolam enhance pain control in prehospital management of traumatic severe pain?

PURPOSE

Midazolam comedication with morphine is a routine practice in pre and postoperative patients but has not been evaluated in prehospital setting. We aimed to evaluate the comedication effect of midazolam in the prehospital traumatic adults.

METHODS

A prehospital prospective randomized double-blind placebo-controlled trial of intravenous morphine 0.10 mg/kg and midazolam 0.04 mg/kg vs morphine 0.10 mg/kg and placebo. Pain assessment was done using a validated numeric rating scale (NRS). The primary end point was to achieve an efficient analgesic effect (NRS≤3) 20 minutes after the baseline. The secondary end points were treatment safety, total morphine dose required until obtaining NRS≤3, and efficient analgesic effect 30 minutes after the baseline.

FINDINGS

Ninety-one patients were randomized into midazolam (n=41) and placebo (n=50) groups. No significant difference in proportion of patients with a pain score≤3 was observed between midazolam (43.6%) and placebo (45.7%) after 20 minutes (P=.849). Secondary end points were similar in regard with proportion of patients with a pain score≤3 at T30, the side effects and adverse events except for drowsiness in midazolam vs placebo, 43.6% vs 6.5% (P<.001). No significant difference in total morphine dose was observed, that is, midazolam (14.09 mg±6.64) vs placebo (15.53 mg±6.27) (P=.315).

CONCLUSIONS

According to our study, midazolam does not enhance pain control as an adjunctive to morphine regimen in the management of trauma-induced pain in prehospital setting. However, such midazolam use seems to be associated with an increase in drowsiness.

Structured sedation programs in the emergency department, hospital and other acute settings: protocol for systematic review of effects and events

BACKGROUND

The use of procedural sedation outside the operating theatre has increased in hospital settings and has gained popularity among non-anesthesiologists. Sedative agents used for procedural pain, although effective, also pose significant risks to the patient if used incorrectly. There is currently no universally accepted program of education for practitioners using or introducing procedural sedation into their practice. There is emerging literature identifying structured procedural sedation programs (PSPs) as a method of ensuring a standardized level of competency among staff and reducing risks to the patient. We hypothesize that programs of education for healthcare professionals using procedural sedation outside the operating theatre are beneficial in improving patient care, safety, practitioner competence and reducing adverse event rates.

METHODS/DESIGN

Electronic databases will be systematically searched for studies (randomized and non-randomized) examining the effectiveness of structured PSPs from 1966 to present. Database searches will be supplemented by contact with experts, reference and citation checking, and a grey literature search. No language restriction will be imposed. Screening of titles and abstracts, and data extraction will be performed by two independent reviewers. All disagreements will be resolved by discussion with an independent third party. Data analysis will be completed adhering to procedures outlined in the Cochrane Handbook of Systematic Reviews of Interventions. If the data allows, a meta-analysis will be performed.

DISCUSSION

This review will cohere evidence on the effectiveness of structured PSPs on sedation events and patient outcomes within the hospital and other acute care settings. In addition, it will examine key components identified within a PSP associated with patient safety and improved patient outcomes.

TRIAL REGISTRATION

PROSPERO registration number: CRD42013003851.

Adverse events of conscious sedation in ambulatory spine procedures

BACKGROUND CONTEXT

Interventional spine procedures are commonly performed in the ambulatory surgical setting, often using conscious sedation. The rate of adverse events with conscious sedation has not been previously assessed in the interventional spine procedure setting.

PURPOSE

The goal of this study was to determine the rate of adverse events when using conscious sedation in the ambulatory interventional spine setting.

STUDY DESIGN

A retrospective cohort chart review analysis was performed on all interventional spine procedures performed during one calendar year at a university-affiliated ambulatory surgery center by six nonanesthesia-trained spine interventionalists.

PATIENT SAMPLE

Of the 3,342 procedures performed that year, 2,494 charts (74.6%) were available for review.

OUTCOME MEASURES

Adverse events were documented immediately after the procedure and at a maximum 3-day follow-up phone call.

METHODS

The rate and type of adverse events were analyzed and compared between those who received conscious sedation with local anesthesia and those who received local anesthesia alone.

RESULTS

Of the 2,494 cases reviewed, 1,228 spine procedures were performed with local anesthesia and conscious sedation, and 1,266 procedures were performed with local anesthesia alone. Of these cases, 66 immediate adverse events (5.12%) were documented in the conscious sedation group, and 61 immediate adverse events (4.82%) were documented in the local anesthesia alone group. At maximum 3-day follow-up, 670 patients of the conscious sedation group were available for contact, and 699 patients were available from the local anesthesia group. Thirty-two adverse events (4.77%) were noted in the conscious sedation group, and 28 adverse events (4.00%) were noted in the local anesthesia group. Comparison of these rates found no significant statistical difference. However, patients in the local anesthesia group had a significantly higher rate of postoperative hypertension. Adverse events reported both immediately and at follow-up were determined to be mild, with no serious adverse events reported.

CONCLUSION

The findings of this study suggest that mild to moderate conscious sedation in interventional spine procedures is associated with low rates of adverse events when established protocols are followed.

Effect of diclofenac with B vitamins on the treatment of acute pain originated by lower-limb fracture and surgery

The aim of this study was to compare the efficacy of diclofenac, for the treatment of acute pain originated by lower-limb fracture and surgery, with that of diclofenac plus B vitamins. This was a single-center, prospective, randomized, and double-blinded clinical trial. Patients with lower-limb closed fractures rated their pain on a 10 cm visual analog scale (VAS). Patients were then randomized to receive diclofenac or diclofenac plus B vitamins (thiamine, pyridoxine, and cyanocobalamin) intramuscularly twice daily. Patient evaluations of pain intensity were recorded throughout two periods: twenty-four hours presurgery and twenty-four hours postsurgical. One hundred twenty-two patients completed the study. The subjects' assessments of limb pain on the VAS showed a significant reduction from baseline values regardless of the treatment group. Diclofenac plus B vitamins combination was more effective to reduce the pain than diclofenac alone. The results showed that the addition of B vitamins to diclofenac increased its analgesic effect. The novelty of this paper consists in that diclofenac and diclofenac plus B vitamins were useful for treatment of acute pain originated by lower-limb fracture and surgery.

Review of studies and guidelines on fasting and procedural sedation at the emergency department

AIM

Procedural sedation and analgesia allows urgent procedures to be performed safely by preserving patients' airway reflexes. Fasting, which is required before deeper levels of sedation, and where the airway reflexes are not preserved, is difficult to impose in emergencies. This paper aims to synthesise evidence on the need for pre-procedure fasting to minimise aspiration among adults undergoing procedural sedation and analgesia for emergency procedures.

METHODS

Overviews, guidelines with graded recommendations and primary studies on aspiration and pre-procedure fasting in procedural sedation and analgesia were retrieved from Medline, Cochrane, and Center for Reviews and Dissemination Databases. Terms searched were procedural sedation, fasting, emergency and sedation.

RESULTS

One primary study and one guideline were included. The American College of Emergency Physicians Clinical Policies Subcommittee on Procedural Sedation and Analgesia issued a recommendation based on 'preliminary, inconclusive or conflicting evidence, or on panel consensus'. The recommendation states: 'recent food intake is not a contraindication for administering procedural sedation and analgesia...'. The primary study conducted by Bell in an emergency department in Australia compared patients who last ate or drank more than 6 and 2 h from induction, respectively, with those who last ate or drank within 6 and 2 h. There were no cases of aspiration in both groups. Out of 118 patients who fasted, 1 (0.8%) vomited, as did one of 282 patients (0.4%) who did not fast.

CONCLUSIONS

Aspiration risk is expected to be lower in procedural sedation and analgesia than in general anaesthesia. Current guidelines rely on expert consensus due to the lack of primary studies. Contextualisation of existing guidelines are quick and efficient strategies for developing locally relevant tools.

Sufentanil is not superior to morphine for the treatment of acute traumatic pain in an emergency setting: a randomized, double-blind, out-of-hospital trial

STUDY OBJECTIVE

We determine the best intravenous opioid titration protocol by comparing morphine and sufentanil for adult patients with severe traumatic acute pain in an out-of-hospital setting, with a physician providing care.

METHODS

In this double-blind randomized clinical trial, patients were eligible for inclusion if aged 18 years or older, with acute severe pain (defined as a numeric rating scale score ≥ 6/10) caused by trauma. They were assigned to receive either intravenous 0.15 μg/kg sufentanil, followed by 0.075 μg/kg every 3 minutes or intravenous 0.15 mg/kg morphine and then 0.075 mg/kg. The primary endpoint of the study was pain relief at 15 minutes, defined as a numeric rating scale less than or equal to 3 of 10. Secondary endpoints were time to analgesia, adverse events, and duration of analgesia during the first 6 hours.

RESULTS

A total of 108 patients were included, 54 in each group. At 15 minutes, 74% of the patients in the sufentanil group had a numeric rating scale score of 3 or lower versus 70% of those in the morphine group (Δ4%; 95% confidence interval -13% to 21%). At 9 minutes, 65% of the patients in the sufentanil group experienced pain relief versus 46% of those in the morphine group (Δ18%; 95% confidence interval 0.1% to 35%). The duration of analgesia was in favor of the morphine group. Nineteen percent of patients experienced an adverse event in both groups, all mild to moderate.

CONCLUSION

Intravenous morphine titration using a loading dose of morphine followed by strictly administered lower doses at regular intervals remains the criterion standard. Moreover, this study supports the idea that the doses studied should be considered for routine administration in severe pain protocols.

The use of sedation in the radiology department

The use of intravenous sedation and analgesia in patients undergoing interventional diagnostic and therapeutic procedures is increasing. Sedation by non-anaesthetists is considered to be safe, provided that they have received adequate training and have the necessary equipment, facilities, and personnel. This article aims to increase awareness of the safe use of sedative drugs in radiology and provide a practical guideline for minimal and moderate sedation.

Profiling adverse respiratory events and vomiting when using propofol for emergency department procedural sedation

OBJECTIVES

To evaluate the rate of adverse respiratory events and vomiting among ED patients undergoing procedural sedation with propofol.

METHODS

This was a prospective, observational series of patients undergoing procedural sedation. Titrated i.v. propofol was administered via protocol. Fasting status was recorded.

RESULTS

Four hundred patients undergoing sedation were enrolled. Of these 282 (70%, 95% confidence interval [CI] 66-75%) had eaten or drunken within 6 and 2 h, respectively. Median fasting times from a full meal, snack or drink were 7 h (interquartile range [IQR] 5-9 h), 6 h (IQR 4-8 h) and 4 h (IQR 2-6 h), respectively. Overall a respiratory event occurred in 86 patients (22%, 95% CI 18-26%). An airway intervention occurred in 123 patients (31%, 95% CI 26-35%). In 111 cases (90%, 95% CI 60-98%) basic airway manoeuvres were all that was required. No patients were intubated. Two patients vomited (0.5%, 95% CI 0.0-1.6%), one during sedation, one after patient became conversational. One patient developed transient laryngospasm (0.25%, 95% CI 0-1.2%) unrelated to vomiting. There were nil aspiration events (0%, 95% CI 0-0.74%).

CONCLUSIONS

Seventy per cent of patients undergoing ED procedural sedation are not fasted. No patient had a clinically evident adverse outcome. Transient respiratory events occur but can be managed with basic airway interventions making propofol a safe alternative for emergency physicians to provide emergent procedural sedation.

A cost-effectiveness analysis of propofol versus midazolam for procedural sedation in the emergency department

OBJECTIVES

To determine the incremental cost-effectiveness of using propofol versus midazolam for procedural sedation (PS) in adults in the emergency department (ED).

METHODS

The authors conducted a cost-effectiveness analysis from the perspective of the health care provider. The primary outcome was the incremental cost (or savings) to achieve one additional successful sedation with propofol compared to midazolam. A decision model was developed in which the clinical effectiveness and cost of a PS strategy using either agent was estimated. The authors derived estimates of clinical effectiveness and risk of adverse events (AEs) from a systematic review. The cost of each clinical outcome was determined by incorporating the baseline cost of the ED visit, the cost of the drug, the cost of labor of physicians and nurses, the cost and probability of an AE, and the cost and probability of a PS failure. A standard meta-analytic technique was used to calculate the weighted mean difference in recovery times and obtain mean drug doses from patient-level data from a randomized controlled trial. Probabilistic sensitivity analyses were conducted to examine the uncertainty around the estimated incremental cost-effectiveness ratio using Monte Carlo simulation.

RESULTS

Choosing a sedation strategy with propofol resulted in average savings of $17.33 (95% confidence interval [CI] = $24.13 to $10.44) per sedation performed. This resulted in an incremental cost-effectiveness ratio of -$597.03 (95% credibility interval -$6,434.03 to $6,113.57) indicating savings of $597.03 per additional successful sedation performed with propofol. This result was driven by shorter recovery times and was robust to all sensitivity analyses performed.

CONCLUSIONS

These results indicate that using propofol for PS in the ED is a cost-saving strategy.

Sedation practice in a Scottish teaching hospital emergency department

OBJECTIVES

To conduct a prospective survey in a teaching hospital emergency department to evaluate performance according to safe sedation principles, to establish the demographics of those sedated, and to review the drugs used and doses given to patients in the department. Any adverse events were reviewed for identification of preventable causes.

METHODS

Pre-sedation checklists, peri-procedural observations, and patient notes were reviewed for 101 cases from 4 December 2004 to 3 September 2005. There are departmental guidelines outlining the principles of safe sedation.

RESULTS

Emergency department procedural sedation was performed for a variety of acute conditions in patients aged from 7 to 91 years old. A variety of sedation agents were administered, morphine and midazolam being used most frequently. Drug administration, maximum sedation level, and time to recovery and discharge were recorded. Four adverse events were reported, none of which were clinically significant. Departmental guidelines were followed.

CONCLUSION

Emergency department sedation is a safe and effective procedure if appropriately trained practitioners follow the principles of safe sedation.

Low-dose ketamine in addition to propofol for procedural sedation and analgesia in the emergency department

OBJECTIVE

To evaluate the efficacy and safety of low-dose intravenous ketamine in addition to intravenous propofol for procedural sedation and analgesia in the emergency department (ED).

DATA SOURCES

Articles were identified using PubMed (1949-February 2007), MEDLINE (1966-February 2007), EMBASE (1980-February 2007), BioMed Central (to February 2007), the Cochrane Library (to February 2007), International Pharmaceutical Abstracts, and Google Scholar (until February 2007). Reference citations from retrieved publications were also reviewed. Search terms included ketamine, propofol, ketamine-propofol, ketofol, combination, sedation, procedural sedation, conscious sedation, and emergency department.

STUDY SELECTION AND DATA EXTRACTION

All articles on prospective procedural sedation that were published or translated into English and that compared combination ketamine-propofol with an appropriate comparator group were included. Clinically relevant safety endpoints included the frequency of significant hemodynamic and respiratory compromise warranting medical intervention, nausea, vomiting, and emergence reactions. Time until hospital discharge criteria were met and patient satisfaction scores were efficacy endpoints of interest.

DATA SYNTHESIS

Of the 11 trials included in this review, most had small sample sizes and were conducted in non-ED settings. The ketamine-propofol combination demonstrated no additional efficacy over propofol in terms of time to discharge. Although fewer patients given the ketamine-propofol combination experienced significant hemodynamic and respiratory compromise, need for active interventions, including fluid or vasopressor administration, supplemental oxygen, or assisted ventilation did not differ between groups. Patients who received higher doses of adjuvant ketamine reported an increased incidence of nausea, vomiting, and emergence reactions following the procedure. Few studies reported patient satisfaction scores postprocedure, and effect of ketaminepropofol on time-to-discharge criteria met was inconclusive.

CONCLUSIONS

At this time, insufficient clinical evidence exists to recommend the routine use of low-dose ketamine with propofol for procedural sedation in the ED setting.