Recovery from sedation with remifentanil and propofol, compared with morphine and midazolam, for reduction in anterior shoulder dislocation

Pharmacological agents for procedural sedation and analgesia in the emergency department and intensive care unit: a systematic review and network meta-analysis of randomised trials

BACKGROUND

We aimed to evaluate the comparative effectiveness and safety of various i.v. pharmacologic agents used for procedural sedation and analgesia (PSA) in the emergency department (ED) and ICU. We performed a systematic review and network meta-analysis to enable direct and indirect comparisons between available medications.

METHODS

We searched Medline, EMBASE, Cochrane, and PubMed from inception to 2 March 2023 for RCTs comparing two or more procedural sedation and analgesia medications in all patients (adults and children >30 days of age) requiring emergent procedures in the ED or ICU. We focused on the outcomes of sedation recovery time, patient satisfaction, and adverse events (AEs). We performed frequentist random-effects model network meta-analysis and used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to rate certainty in estimates.

RESULTS

We included 82 RCTs (8105 patients, 78 conducted in the ED and four in the ICU) of which 52 studies included adults, 23 included children, and seven included both. Compared with midazolam-opioids, recovery time was shorter with propofol (mean difference 16.3 min, 95% confidence interval [CI] 8.4-24.3 fewer minutes; high certainty), and patient satisfaction was better with ketamine-propofol (mean difference 1.5 points, 95% CI 0.3-2.6 points, high certainty). Regarding AEs, compared with midazolam-opioids, respiratory AEs were less frequent with ketamine (relative risk [RR] 0.55, 95% CI 0.32-0.96; high certainty), gastrointestinal AEs were more common with ketamine-midazolam (RR 3.08, 95% CI 1.15-8.27; high certainty), and neurological AEs were more common with ketamine-propofol (RR 3.68, 95% CI 1.08-12.53; high certainty).

CONCLUSION

When considering procedural sedation and analgesia in the ED and ICU, compared with midazolam-opioids, sedation recovery time is shorter with propofol, patient satisfaction is better with ketamine-propofol, and respiratory adverse events are less common with ketamine.

Comparing Diazepam Plus Fentanyl With Midazolam Plus Fentanyl in the Moderate Procedural Sedation of Anterior Shoulder Dislocations: A Randomized Clinical Trial

BACKGROUND

The reduction of shoulder dislocation requires adequate procedural sedation and analgesia. The mixture of midazolam and fentanyl is reported in the literature, but long-acting benzodiazepines in conjunction with fentanyl are lacking.

STUDY OBJECTIVE

Our aim was to compar e IV diazepam with IV midazolam in moderate procedural sedation (based on the classification of the American Society of Anesthesiologists) for the reduction of shoulder dislocation.

METHODS

This was a randomized controlled clinical trial conducted from April 2019 to December 2019 in the emergency department of a university-affiliated hospital in Tehran, Iran. Participants were adult patients (aged 18-65 years) with anterior shoulder dislocation. Group A (n = 42) received diazepam 0.1 mg/kg plus fentanyl 1 μg/kg IV and group B received midazolam 0.1 mg/kg plus fentanyl 1 μg g/kg IV. Main outcomes measured were onset of muscle relaxation, time taken to reduction, total procedure time, number of the reduction attempts, patient recovery time, the occurrence of the adverse effects, amount of the pain reported by the patients using visual analog scale, and patients and physicians overall satisfaction with the procedure using a Likert scale question.

RESULTS

Eighty-one patients were included. The mean ± standard deviation time of the onset of the muscle relaxation and time taken to reduction was shorter in the diazepam plus fentanyl group (p = 0.016 and p = 0.001, respectively). Adverse effects and pain relief were not statistically different between the two groups. Patient recovery time and total procedure time was shorter in the midazolam plus fentanyl group (p = 0.008 and p = 0.02, respectively). The overall satisfaction of patients and physicians was higher in the diazepam plus fentanyl group.

CONCLUSIONS

As compared with midazolam plus fentanyl, diazepam plus fentanyl was superior in terms of the onset of the muscle relaxation, patient and physician satisfaction, and time taken to reduction.

A Survey of Emergency Providers Regarding the Current Management of Anterior Shoulder Dislocations

Background:

Anterior shoulder dislocations (ASDs) are frequent painful injuries commonly treated in the emergency department. The last decade new potentially less traumatic and painful reduction techniques for ASDs have been introduced. Recent literature comparing best reduction techniques, medication use, and approaches is limited. To better guide future research including the use of these newer techniques, information about the current use of different reduction techniques and medication is needed.

Methods:

Our primary aim was to survey the techniques used by emergency practitioners to reduce ASDs. Our secondary objective was to gather data on medication usage during reduction. To these ends, we surveyed members of the Netherlands Society of Emergency Physicians.

Results:

Forty-four percent of respondents reported using a traction-based technique (Hippocrates or Stimson). Biomechanical techniques were used by 40% of respondents. Twelve percent reported using the Kocher leverage-based technique. Five percent of the techniques used could not be classified. A wide variety of procedural sedation and pain management interventions were reported, with an opioid and propofol being used most commonly. Approximately 9% of the reductions were attempted without any medications.

Conclusions:

To our knowledge, this is the first study of its kind on ASD management by emergency practitioners. Our results indicate that Dutch emergency practitioners employ all three classes of reduction techniques: traction-countertraction most commonly, closely followed by biomechanical techniques. Medication use during repositioning varied widely. Per our survey, emergency practitioners are desirous of an evidence-based guideline for ASD management.

Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018

Supplemental Digital Content is available in the text.

Review article: Best practice management of common shoulder injuries and conditions in the emergency department (part 4 of the musculoskeletal injuries rapid review series)

Shoulder injuries are a commonly presenting complaint to the ED. In the absence of an obvious deformity, they can be difficult to assess and definitively diagnose because of the multiple structures that cause shoulder pain, the acuity and severity of pain and the lack of range of motion in the ED setting. The quality of ED care provided to patients with musculoskeletal shoulder pain is crucial to ensure the best possible outcomes for the patient. This rapid review investigated best practice for the assessment and management of common shoulder injuries and conditions in the ED. Databases were searched in 2017, including PubMed, CINAHL, EMBASE, TRIP and the grey literature, including relevant organisational websites. Primary studies, systematic reviews and guidelines published in English-language in the past 12 years that addressed the acute assessment, management, follow-up plan or prognosis were considered for inclusion. Data extraction of included articles was conducted, followed by quality appraisal to rate the level of evidence. The search revealed 1902 articles, of which 73 were included in the review (n = 12 primary articles, n = 49 systematic reviews and n = 12 guidelines). This rapid review provides clinicians who manage shoulder dislocations, fractures and soft tissue injuries in the ED a summary of the best available evidence to enhance the quality of care for optimal patient outcomes. There is strong evidence to support taking a thorough history and physical examination, with cautious use of special tests because of their poor diagnostic accuracy. Key points regarding the diagnosis and management of these injuries are provided.

Anterior Shoulder Dislocation Reduction Managed Either with Midazolam or Propofol in Combination with Fentanyl

Objective

Procedural Sedation and Analgesia is used in managing emergency painful procedures. The aim of this study is to compare the effects of propofol and midazolam on haemodynamic parameters when used in combination with fentanyl in isolated anterior shoulder dislocations and to measure the patient and physician satisfactions.

Methods

The study is a randomised single blind prospective trial. All procedural sedations were performed by emergency medicine specialists and the shoulder reductions were performed by orthopaedic surgeons. Two groups were defined. Group A received intravenous fentanyl and midazolam and Group B received intravenous fentanyl and propofol. The orthopaedic surgeons were not informed about the drugs. The emergency medicine specialist observed the patients. The patients and the orthopaedic surgeons were asked for a satisfaction scoring.

Results

Midazolam group consisted of 37 patients and propofol group consisted of 38 patients. Both groups were similar in demographic characteristics and pre-procedural vital signs. There was only one statistically significant difference at one time and it was the 5th minutes SpO2 levels between groups. There were statistically significant changes in the measurements of vital parameters in both groups when compared with the baseline levels. However none of them was clinically important. In midazolam and propofol group, 10.8% and 10.5% respectively had respiratory compromise. Patient and physician satisfactions were similar in both groups.

Conclusions

Midazolam and propofol are both relatively safe drugs using in combination with fentanyl in anterior shoulder dislocations. Patients and physicians can be highly satisfied with the two groups of drugs. (Hong Kong j.emerg.med. 2014;21:346-353)

Biomechanical reposition techniques in anterior shoulder dislocation: a randomised multicentre clinical trial- the BRASD-trial protocol

INTRODUCTION

Glenohumeral (shoulder) dislocations are the most common large joint dislocations seen in the emergency department (ED). They cause pain, often severe, and require timely interventions to minimise discomfort and tissue damage. Commonly used reposition or relocation techniques often involve traction and/or leverage. These techniques have high success rates but may be painful and time consuming. They may also cause complications. Recently, other techniques-the biomechanical reposition techniques (BRTs)-have become more popular since they may cause less pain, require less time and cause fewer complications. To our knowledge, no research exists comparing the various BRTs. Our objective is to establish which BRT or BRT combination is fastest, least painful and associated with the lowest complication rate for adult ED patients with anterior glenohumeral dislocations (AGDs).

METHODS AND ANALYSIS

Adults presenting to the participating EDs with isolated AGDs, as determined by radiographs, will be randomised to one of three BRTs: Cunningham, modified Milch or scapular manipulation. Main study parameters/endpoints are ED length of stay and patients' self-report of pain. Secondary study parameters/endpoints are procedure times, need for analgesic and/or sedative medications, iatrogenic complications and rates of successful reduction.

ETHICS AND DISSEMINATION

Non-biomechanical AGD repositioning techniques based on traction and/or leverage are inherently painful and potentially harmful. We believe that the three BRTs used in this study are more physiological, more patient friendly, less likely to cause pain, more time efficient and less likely to produce complications. By comparing these three techniques, we hope to improve the care provided to adults with acute AGDs by reducing their ED length of stay and minimising pain and procedure-related complications. We also hope to define which of the three BRTs is quickest, most likely to be successful and least likely to require sedative or analgesic medications to achieve reduction.

TRIAL REGISTRATION NUMBER

NTR5839.

Options and Considerations for Procedural Sedation in Pediatric Imaging

As pediatric imaging capabilities have increased in scope, so have the complexities of providing procedural sedation in this environment. While efforts by many organizations have dramatically increased the safety of pediatric procedural sedation in general, radiology sedation creates several special challenges for the sedation provider. These challenges require implementation of additional safeguards to promote safety during sedation while maintaining effective and efficient care. Multiple agent options are available, and decisions regarding which agent(s) to use should be determined by both patient needs (i.e., developmental capacities, underlying health status, and previous experiences) and procedural needs (i.e., duration, need for immobility, and invasiveness). Increasingly, combinations of agents to either achieve the conditions required or mitigate/counterbalance adverse effects of single agents are being utilized with success. To continue to provide effective imaging sedation, it is incumbent on sedation providers to maintain familiarity with continuing evolutions within radiology environments, as well as comfort and competence with multiple sedation agents/regimens. This review discusses the challenges associated with radiology sedation and outlines various available agent options and combinations, with the intent of facilitating appropriate matching of agent(s) with patient and procedural needs.

The use of propofol for procedural sedation in emergency departments

BACKGROUND

There is increasing evidence that propofol is efficacious and safe for procedural sedation (PS) in the emergency department (ED) setting. However, propofol has a narrow therapeutic window and lacks of a reversal agent. The aim of this review was to cohere the evidence base regarding the efficacy and safety profile of propofol when used in the ED setting for PS.

OBJECTIVES

To identify and evaluate all randomized controlled trials (RCTs) comparing propofol with alternative drugs (benzodiazepines, barbiturates, etomidate and ketamine) used in the ED setting for PS.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 9), MEDLINE (1950 to September week 2 2013) and EMBASE (1980 to week 2 2013). We searched the Current Controlled Trials metaRegister of Clinical Trials (compiled by Current Science) (September 2013). We checked the reference lists of trials and contacted trial authors. We imposed no language restriction. We re-ran the search in February 2015. We will deal with the one study awaiting classification when we update the review.

SELECTION CRITERIA

RCTs comparing propofol to alternative drugs (benzodiazepines, barbiturates, etomidate and ketamine) used in the ED setting for PS in participants of all ages.

DATA COLLECTION AND ANALYSIS

Two authors independently performed data extraction. Two authors performed trial quality assessment. We used mean difference (MD), odds ratio (OR) and 95% confidence intervals (CI) to measure effect sizes. Two authors independently assessed and rated the methodological quality of each trial using The Cochrane Collaboration tool for assessing risk of bias.

MAIN RESULTS

Ten studies (813 participants) met the inclusion criteria. Two studies only included participants 18 years and younger; six studies only included participants 18 years and older; one study included participants between 16 and 65 years of age and one study included only adults but did not specify the age range. Eight of the included studies had a high risk of bias. The included studies were clinically heterogeneous. We undertook no meta-analysis.The primary outcome measures of this review were: adverse effects (as defined by the study authors) and participant satisfaction (as defined by the study authors). In one study comparing propofol/fentanyl with ketamine/midazolam, delayed adverse reactions (nightmares and behavioural change) were noted in 10% of the ketamine/midazolam group and none in the propofol/fentanyl group. Seven individual studies reported no evidence of a difference in adverse effects between intravenous propofol, with and without adjunctive analgesic agents, and alternative interventions. Three individual studies reported no evidence of a difference in pain at the injection site between intravenous propofol and alternative interventions. Four individual studies reported no evidence of a difference in participant satisfaction between intravenous propofol, with and without adjunctive analgesic agents, and alternative interventions (ketamine, etomidate, midazolam). All the studies employed propofol without the use of an adjunctive analgesic and all, except one, were small (fewer than 100 participants) studies. The quality of evidence for the adverse effects and participant satisfaction outcomes was very low.Nine included studies (eight comparisons) reported all the secondary outcome measures of the review except mortality. It was not possible to pool the results of the included studies for any of the secondary outcome measures because the comparator interventions were different and the measures were reported in different ways. Seven individual studies reported no evidence of difference in incidence of hypoxia between intravenous propofol, with and without adjunctive analgesic agents, and alternative interventions.

AUTHORS' CONCLUSIONS

No firm conclusions can be drawn concerning the comparative effects of administering intravenous propofol, with or without an adjunctive analgesic agent, with alternative interventions in participants undergoing PS in the ED setting on adverse effects (including pain at the injection site) and participant satisfaction. The review was limited because no two included studies employed the same comparator interventions, and because the number of participants in eight of the included studies were small (fewer than 100 participants).

Procedural sedation and analgesia in the emergency department

Procedural sedation and analgesia (PSA) is a core part of modern emergency department (ED) care allowing the rapid provision of important procedures. The safe delivery of a PSA service requires an appropriately staffed and equipped environment backed up by an ongoing system of training, audit and review. Topics covered in this review include: the evidence relating to the agents used; patient care before, during and after the procedure; the outcomes of ED PSA; and, the special considerations relating to PSA in children.

Propofol Versus Midazolam for Procedural Sedation of Anterior Shoulder Dislocation in Emergency Department: A Randomized Clinical Trial

Background:

Anterior shoulder dislocation (ASD) is one of the most common reasons for referrals to emergency departments (ED). Usually, a combination of an intravenous narcotic and a benzodiazepine is used for procedural sedation and analgesia (PSA) in such cases.

Objectives:

This study compares the efficacy of two combinations to reduce ASD.

Patients and Methods:

The subjects in this clinical trial consisted of 48 patients with ASD who were randomly assigned to midazolam/fentanyl and propofol/fentanyl groups for PSA. The two groups were compared to the time interval between injection and induction of sedation (T1), duration of time from sedation to awakening (T2), the duration of time between sedation and full awareness to time, location and individuals (T3), and possible side effects.

Results:

Twenty-nine subjects (60.4%) were sedated with midazolam and 19 (39.6%) were sedated with propofol. During the procedure, one patient in the propofol group experienced apnea (P = 0.39) and three patients (one in the midazolam group and two in the propofol group) experienced bradycardia (P = 0.34). The mean T1, T2, and T3 were significantly shorter in the propofol group (P < 0.001).

Conclusions:

It seems that propofol and fentanyl can be used as a safe and fast combination for PSA in the reduction of ASD.

Propofol for Procedural Sedation in the Emergency Department: A Qualitative Systematic Review

OBJECTIVE:

To evaluate the efficacy and safety of propofol compared to other agents for procedural sedation of adults in the emergency department (ED) and to review the use of opioids in conjunction with propofol for procedural sedation in the ED.

DATA SOURCES:

PubMed (1949-December 2012) and EMBASE (1980-December 2012) were searched using combinations of the following search terms: (procedural sedation or conscious sedation [MESH]) and propofol. A manual search of references was also performed.

STUDY SELECTION AND DATA EXTRACTION:

English-language, full reports of randomized controlled trials (RCTs) and observational studies evaluating propofol use in adults undergoing procedural sedation in the ED were included if they reported efficacy or safety outcomes. Two reviewers independently assessed each article for inclusion, data extraction, and study limitations.

DATA SYNTHESIS:

Thirteen RCTs and 20 observational studies meeting our inclusion criteria were retrieved. Regardless of the agent used for sedation, procedural success was greater than 80% and most trials demonstrated no statistically significant difference in the incidence of respiratory depression with propofol compared to alternatives. One RCT showed a significantly greater percent decrease in systolic blood pressure from baseline in those who received propofol compared to ketamine. Where reported, no significant difference was found in patient recall, pain, and satisfaction when opioids were added to propofol compared to propofol alone; the addition of opioids may have resulted in a higher incidence of respiratory adverse events.

CONCLUSIONS:

Propofol for procedural sedation is a reasonable alternative for use in the ED, with comparative efficacy and safety to other alternatives. Use of opioids in addition to propofol may not provide added benefit but does contribute to increased rates of adverse events.

Buprenorphine/naloxone inhibition of remifentanil procedural sedation

Opioid analgesics are the mainstay of treatment of moderate and severe pain. Remifentanil is an ultrashort acting opioid analgesic used in emergency department (ED)procedural sedation, whereas buprenorphine/naloxone (Suboxone) is an opioid agonist-antagonist combination used in the treatment of addiction-prone individuals. We report here a case of buprenorphine/naloxone inhibition of remifentanil analgesia in a patient undergoing ED procedural sedation.