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Khan MT, Khan AR, Rohail S, Raza FA, Ahmed S, Siddiqui A, Kumar J, Yasinzai AQK, Sohail AH, Goyal A. Safety of procedural sedation in emergency department settings among the adult population: a systematic review and meta-analysis of randomized controlled trials. Intern Emerg Med 2024:10.1007/s11739-024-03697-2. [PMID: 39102153 DOI: 10.1007/s11739-024-03697-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 06/25/2024] [Indexed: 08/06/2024]
Abstract
Procedural sedation and analgesia (PSA) are a common practice in emergency departments (EDs), aiming to alleviate pain, anxiety, and discomfort during various medical procedures. We have undertaken a systematic review and meta-analysis with the aim of assessing the incidence of adverse events associated with PSA, including those related to individual drugs and various drug combinations. The study adhered to PRISMA guidelines for a systematic review and meta-analysis of adverse events in ED sedation. A comprehensive search strategy was employed across ten databases, supplemented by searches on clinicaltrials.gov and manual reviews of reference lists. Data extraction focused on medication administration and adverse events. The study considered four types of adverse events: cardiac, respiratory, gastrointestinal, and neurological. Only randomized controlled trials (RCTs) focusing on PSA administered to adult patients within the ED setting were included. The statistical analysis employed OpenMeta Analyst to conduct a one-arm meta-analysis, with findings presented alongside their corresponding 95% Confidence Intervals. Forest plots were constructed to combine and evaluate results, and sensitivity analyses were performed to identify sources of heterogeneity. From a literature search of 4246 records, 32 RCTs were deemed suitable for this meta-analysis. The analysis included 6377 procedural sedations. The most common adverse event was hypoxia, with an incidence rate of 78.5 per 1000 sedations (95% CI = 77.5-133.5). This was followed by apnea and hypotension, with incidence rates of 31 (95% CI = 19.5-41.8) and 28.1 (95% CI = 17.4-38.9) per 1,000 sedations, respectively. Agitation and vomiting each occurred in 15.6 per 1,000 sedations (95% CI = 8.7-22.6). Severe adverse events were rare, with bradycardia observed in 16.7 per 1,000 sedations, laryngospasm in 2.9 per 1,000 sedations (95% CI = - 0.1 to 6), intubation in 10.8 per 1,000 sedations (95% CI = 4-17), and aspiration in 2.7 per 1,000 sedations (95% CI = - 0.3 to 5.7). Ketamine is found to be the safest option in terms of respiratory adverse events, with the lowest rates of apnea and hypoxia, making it the least respiratory depressant among the evaluated drugs. Etomidate has the least occurrence of hypotension when used alone. Propofol has the highest incidence of hypotension when used alone and ranks second in hypoxia-related adverse events after midazolam. Using combinations of sedating agents, such as propofol and ketamine, has been found to offer several advantages over single drugs, especially in reducing adverse events like vomiting, intubation difficulty, hypotension, bradycardia, and laryngospasm. The combination significantly reduces the incidence of hypotension compared to using propofol or ketamine individually. Despite the regular use of procedural sedation, it can sometimes lead to serious adverse events. Respiratory issues like apnea and hypoxia, while not common, do occur more often than cardiovascular problems such as hypotension. However, the least frequent respiratory complications, which can also pose a threat to life, include laryngospasm, aspiration, and intubation. These incidents are extremely rare.
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Affiliation(s)
- Muhammad Taha Khan
- Department of Internal Medicine, Karachi Medical and Dental College, Karachi, Pakistan
| | - Ayesha Rahman Khan
- Department of Internal Medicine, Karachi Medical and Dental College, Karachi, Pakistan
| | - Samia Rohail
- Department of Internal Medicine, Karachi Medical and Dental College, Karachi, Pakistan
| | - Fatima Ali Raza
- Department of Internal Medicine, Karachi Medical and Dental College, Karachi, Pakistan
| | - Shahzaib Ahmed
- Department of Internal Medicine, Fatima Memorial Hospital College of Medicine and Dentistry, Lahore, Pakistan
| | - Amna Siddiqui
- Department of Internal Medicine, Karachi Medical and Dental College, Karachi, Pakistan
| | - Jai Kumar
- Department of Internal Medicine, Karachi Medical and Dental College, Karachi, Pakistan
| | | | - Amir Humza Sohail
- Department of Surgery, University of New Mexico, Albuquerque, NM, USA
| | - Aman Goyal
- Department of Internal Medicine, Seth GS Medical College and KEM Hospital, Mumbai, India, 400012.
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Sharif S, Kang J, Sadeghirad B, Rizvi F, Forestell B, Greer A, Hewitt M, Fernando SM, Mehta S, Eltorki M, Siemieniuk R, Duffett M, Bhatt M, Burry L, Perry JJ, Petrosoniak A, Pandharipande P, Welsford M, Rochwerg B. Pharmacological agents for procedural sedation and analgesia in the emergency department and intensive care unit: a systematic review and network meta-analysis of randomised trials. Br J Anaesth 2024; 132:491-506. [PMID: 38185564 DOI: 10.1016/j.bja.2023.11.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/29/2023] [Accepted: 11/30/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND We aimed to evaluate the comparative effectiveness and safety of various i.v. pharmacologic agents used for procedural sedation and analgesia (PSA) in the emergency department (ED) and ICU. We performed a systematic review and network meta-analysis to enable direct and indirect comparisons between available medications. METHODS We searched Medline, EMBASE, Cochrane, and PubMed from inception to 2 March 2023 for RCTs comparing two or more procedural sedation and analgesia medications in all patients (adults and children >30 days of age) requiring emergent procedures in the ED or ICU. We focused on the outcomes of sedation recovery time, patient satisfaction, and adverse events (AEs). We performed frequentist random-effects model network meta-analysis and used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to rate certainty in estimates. RESULTS We included 82 RCTs (8105 patients, 78 conducted in the ED and four in the ICU) of which 52 studies included adults, 23 included children, and seven included both. Compared with midazolam-opioids, recovery time was shorter with propofol (mean difference 16.3 min, 95% confidence interval [CI] 8.4-24.3 fewer minutes; high certainty), and patient satisfaction was better with ketamine-propofol (mean difference 1.5 points, 95% CI 0.3-2.6 points, high certainty). Regarding AEs, compared with midazolam-opioids, respiratory AEs were less frequent with ketamine (relative risk [RR] 0.55, 95% CI 0.32-0.96; high certainty), gastrointestinal AEs were more common with ketamine-midazolam (RR 3.08, 95% CI 1.15-8.27; high certainty), and neurological AEs were more common with ketamine-propofol (RR 3.68, 95% CI 1.08-12.53; high certainty). CONCLUSION When considering procedural sedation and analgesia in the ED and ICU, compared with midazolam-opioids, sedation recovery time is shorter with propofol, patient satisfaction is better with ketamine-propofol, and respiratory adverse events are less common with ketamine.
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Affiliation(s)
- Sameer Sharif
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada; Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
| | - Jasmine Kang
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Fayyaz Rizvi
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ben Forestell
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Alisha Greer
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada; Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Mark Hewitt
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada; Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Shannon M Fernando
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada; Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health System; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Mohamed Eltorki
- Department of Pediatrics, Division of Pediatric Emergency Medicine, McMaster University, Ottawa, ON, Canada
| | - Reed Siemieniuk
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Mark Duffett
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Maala Bhatt
- Department of Medicine, Sinai Health System, Interdepartmental Division of Critical Care Medicine, Toronto, ON, Canada
| | - Lisa Burry
- Department of Medicine, Sinai Health System; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Pharmacy, Sinai Health System, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Andrew Petrosoniak
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada
| | - Pratik Pandharipande
- Department of Anesthesiology, Division of Critical Care, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Michelle Welsford
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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Beaty EH, Fernando RJ, Jacobs ML, Winter GG, Bulla C, Singleton MJ, Patel NJ, Bradford NS, Bhave PD, Royster RL. Comparison of Bolus Dosing of Methohexital and Propofol in Elective Direct Current Cardioversion. J Am Heart Assoc 2022; 11:e026198. [PMID: 36129031 DOI: 10.1161/jaha.122.026198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Methohexital and propofol can both be used as sedation for direct current cardioversion (DCCV). However, there are limited data comparing these medications in this setting. We hypothesized that patients receiving methohexital for elective DCCV would be sedated more quickly, recover from sedation faster, and experience less adverse effects. Methods and Results This was a prospective, blinded randomized controlled trial conducted at a single academic medical center. Eligible participants were randomly assigned to receive either methohexital (0.5 mg/kg) or propofol (0.8 mg/kg) as a bolus for elective DCCV. The times from bolus of the medication to achieving a Ramsay Sedation Scale score of 5 to 6, first shock, eyes opening on command, and when the patient could state their age and name were obtained. The need for additional medication dosing, airway intervention, vital signs, and medication side effects were also recorded. Seventy patients who were randomized to receive methohexital (n=37) or propofol (n=33) were included for analysis. The average doses of methohexital and propofol were 0.51 mg/kg and 0.84 mg/kg, respectively. There were no significant differences between methohexital and propofol in the time from end of injection to loss of conscious (1.4±1.8 versus 1.1±0.5 minutes; P=0.33) or the time to first shock (1.7±1.9 versus 1.4±0.5 minutes; P=0.31). Time intervals were significantly lower for methohexital compared with propofol in the time to eyes opening on command (5.1±2.5 versus 7.8±3.7 minutes; P=0.0005) as well as at the time to the ability to answer simple questions of age and name (6.0±2.6 versus 8.6±4.0 minutes; P=0.001). The methohexital group experienced less hypotension (8.1% versus 42.4%; P<0.001) and less hypoxemia (0.0% versus 15.2%; P=0.005), had lower need for jaw thrust/chin lift (16.2% versus 42.4%; P=0.015), and had less pain on injection compared with propofol using the visual analog scale (7.2±9.7 versus 22.4±28.1; P=0.003). Conclusions In this model of fixed bolus dosing, methohexital was associated with faster recovery, more stable hemodynamics, and less hypoxemia after elective DCCV compared with propofol. It can be considered as a preferred agent for sedation for DCCV. Registration URL: https://www.clinicaltrials.gov/ct; Unique identifier: NCT04187196.
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Affiliation(s)
- Elijah H Beaty
- Section on Cardiovascular Medicine, Department of Internal Medicine Wake Forest School of Medicine Winston-Salem NC
| | - Rohesh J Fernando
- Department of Anesthesiology Wake Forest School of Medicine Winston-Salem NC
| | | | - Gillian G Winter
- Section on Cardiovascular Medicine, Department of Internal Medicine Wake Forest School of Medicine Winston-Salem NC
| | - Catalina Bulla
- Hospital Medicine Cleveland Clinic Florida, Indian River Hospital Vero Beach FL
| | | | - Neel J Patel
- Section on Cardiovascular Medicine, Department of Internal Medicine Wake Forest School of Medicine Winston-Salem NC
| | - Natalie S Bradford
- Section on Cardiovascular Medicine, Department of Internal Medicine Wake Forest School of Medicine Winston-Salem NC
| | - Prashant D Bhave
- Section on Cardiovascular Medicine, Department of Internal Medicine Wake Forest School of Medicine Winston-Salem NC
| | - Roger L Royster
- Department of Anesthesiology Wake Forest School of Medicine Winston-Salem NC
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Abstract
Direct current cardioversion is a low-risk and standard procedure to restore normal sinus rhythm in patients with tachyarrhythmias. It requires sedation to facilitate the procedure, as it is painful and distressful. The preferred anesthetic drug must be short acting, producing conscious sedation, to enable rapid recovery after the procedure. In this sense, this narrative review focuses on the critical analysis of recent randomized studies and presents about the safety and effectiveness of propofol, comparing it with other established sedatives, mainly etomidate and midazolam. The research was performed on MEDLINE database with Propofol and Cardioversion keywords. In most cases, propofol comes to be the best option, with a quick recovery time and low rates of side effects. Different studies have demonstrated no inferiority when comparing to other drugs and, when these adverse events happened, they were easily and quickly handled. Exceptions in this scenario are those patients, particularly the elderly, with baseline important structural heart disease, in which etomidate with fentanyl has been pointed to lead to better hemodynamic stability.
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Affiliation(s)
- Bruna Galvão de Wafae
- Medical Sciences Faculty, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Rose Mary Ferreira da Silva
- Department of Internal Medicine, Faculty of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Henrique Horta Veloso
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
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Abstract
An aging worldwide population demands that anesthesiologists consider geriatrics a unique subset of patients requiring customization of practice. This article reviews the current literature investigating physiologic changes of the elderly that affect pharmacokinetics and pharmacodynamics. Changes in drug absorption, distribution, metabolism, and excretion are discussed as well as the ultimate effects of medications. Implications for practice regarding specific anesthetic and analgesic drugs are addressed. Despite the immense body of research that contributes to understanding of geriatric pharmacology, elderly patients often are excluded from rigorous research trials, and further scientific investigation to inform best practices for this group of patients is needed.
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Affiliation(s)
- Tate M Andres
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN, USA.
| | - Tracy McGrane
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
| | - Matthew D McEvoy
- Perioperative Consult Service, Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
| | - Brian F S Allen
- Regional and Acute Pain Medicine Fellowship, Regional and Acute Pain Medicine Service, Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
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Painful Recall in Elective Electrical Cardioversion with Propofol and the Need for Additional Analgesia. Cardiol Res Pract 2018; 2018:2363062. [PMID: 30140454 PMCID: PMC6081497 DOI: 10.1155/2018/2363062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 05/03/2018] [Accepted: 06/24/2018] [Indexed: 11/17/2022] Open
Abstract
Introduction Electrical cardioversion (ECV) is a short but painful procedure for treating cardiac dysrhythmias. There is a wide variation regarding the medication strategy to facilitate this procedure. Many different sedative techniques for ECV are described. Currently, the optimal medication strategy to prevent pain in ECV has yet to be established. The role for additional analgesic agents to prevent pain during the procedure remains controversial, and evidence is limited. Methods We conducted a prospective multicenter study to determine the incidence of painful recall in ECV with propofol as a sole agent for sedation, in order to assess the indication for additional opioids. In all patients, sedation was induced with propofol titrated till loss of eyelash reflex and nonresponsiveness to stimuli, corresponding to Ramsay Sedation Score level 5-6. ECV was performed with extracardiac biphasic electrical shocks. The primary outcome was painful recall of the procedure, defined as numeric pain rating scale (NRS) ≥ 1. NRS ≥ 4 is considered inadequately treated pain. Secondary outcome parameters were pain at the side of the defipads and muscle pain after ECV. Results A total of 232 patients were enrolled in this study. Six patients were excluded due to missing data or violation of study protocol. Three patients reported recall of the procedure, and one patient (0.4%) reported recall of severe pain during the procedure with NRS 7. Two patients (0.9%) reported recall of mild pain with NRS 1-3. Complete amnesia was observed in 223 patients (98.7%), with NRS 0. The mean of the total dose of propofol was 1.1 mg/kg. Fifteen patients (6.6%) experienced pain at the side of the defipads, and six patients (2.7%) complained of muscle pain after the procedure. Conclusions In this prospective multicenter study, propofol as a sole agent provided good conditions for ECV with a low incidence of recall. Effective sedation and complete amnesia was achieved in 98.7% of the patients, 0.4% of patients reported recall of severe pain during the procedure, and 0.9% of patients experienced mild pain during the ECV.
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Between- and within-site variation in medication choices and adverse events during procedural sedation for electrical cardioversion of atrial fibrillation and flutter. CAN J EMERG MED 2017; 20:370-376. [PMID: 28587704 DOI: 10.1017/cem.2017.20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
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.
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Gerstein NS, Young A, Schulman PM, Stecker EC, Jessel PM. Sedation in the Electrophysiology Laboratory: A Multidisciplinary Review. J Am Heart Assoc 2016; 5:JAHA.116.003629. [PMID: 27412904 PMCID: PMC4937286 DOI: 10.1161/jaha.116.003629] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Neal S Gerstein
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine, Albuquerque, NM
| | - Andrew Young
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR
| | - Peter M Schulman
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR
| | - Eric C Stecker
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR
| | - Peter M Jessel
- Knight Cardiovascular Institute, VA Portland Health Care System, Portland, OR
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Bellolio MF, Gilani WI, Barrionuevo P, Murad MH, Erwin PJ, Anderson JR, Miner JR, Hess EP. Incidence of Adverse Events in Adults Undergoing Procedural Sedation in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med 2016; 23:119-34. [PMID: 26801209 PMCID: PMC4755157 DOI: 10.1111/acem.12875] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 07/27/2015] [Accepted: 08/27/2015] [Indexed: 12/29/2022]
Abstract
OBJECTIVES This was a systematic review and meta-analysis to evaluate the incidence of adverse events in adults undergoing procedural sedation in the emergency department (ED). METHODS Eight electronic databases were searched, including MEDLINE, EMBASE, EBSCO, CINAHL, CENTRAL, Cochrane Database of Systematic Reviews, Web of Science, and Scopus, from January 2005 through 2015. Randomized controlled trials and observational studies of adults undergoing procedural sedation in the ED that reported a priori selected outcomes and adverse events were included. Meta-analysis was performed using a random-effects model and reported as incidence rates with 95% confidence intervals (CIs). RESULTS The search yielded 2,046 titles for review. Fifty-five articles were eligible, including 9,652 procedural sedations. The most common adverse event was hypoxia, with an incidence of 40.2 per 1,000 sedations (95% CI = 32.5 to 47.9), followed by vomiting with 16.4 per 1,000 sedations (95% CI = 9.7 to 23.0) and hypotension with 15.2 per 1,000 sedations (95% CI = 10.7 to 19.7). Severe adverse events requiring emergent medical intervention were rare, with one case of aspiration in 2,370 sedations (1.2 per 1,000), one case of laryngospasm in 883 sedations (4.2 per 1,000), and two intubations in 3,636 sedations (1.6 per 1,000). The incidence of agitation and vomiting were higher with ketamine (164.1 per 1,000 and 170.0 per 1,000, respectively). Apnea was more frequent with midazolam (51.4 per 1,000), and hypoxia was less frequent in patients who received ketamine/propofol compared to other combinations. The case of laryngospasm was in a patient who received ketamine, and the aspiration and intubations were in patients who received propofol. When propofol and ketamine are combined, the incidences of agitation, apnea, hypoxia, bradycardia, hypotension, and vomiting were lower compared to each medication separately. CONCLUSIONS Serious adverse events during procedural sedation like laryngospasm, aspiration, and intubation are exceedingly rare. Quantitative risk estimates are provided to facilitate shared decision-making, risk communication, and informed consent.
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Affiliation(s)
- M. Fernanda Bellolio
- Department of Emergency MedicineMayo ClinicRochesterMN
- Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterMN
| | | | - Patricia Barrionuevo
- Division of Preventive, Occupational, and Aerospace MedicineMayo ClinicRochesterMN
- Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterMN
| | - M. Hassan Murad
- Division of Preventive, Occupational, and Aerospace MedicineMayo ClinicRochesterMN
- Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterMN
| | | | | | - James R. Miner
- Department of Emergency MedicineUniversity of Minnesota Medical SchoolMinneapolisMN
- Department of Emergency MedicineHennepin County Medical CenterMinneapolisMN
| | - Erik P. Hess
- Department of Emergency MedicineMayo ClinicRochesterMN
- Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterMN
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Wakai A, Blackburn C, McCabe A, Reece E, O'Connor G, Glasheen J, Staunton P, Cronin J, Sampson C, McCoy SC, O'Sullivan R, Cummins F. The use of propofol for procedural sedation in emergency departments. Cochrane Database Syst Rev 2015; 2015:CD007399. [PMID: 26222247 PMCID: PMC6517206 DOI: 10.1002/14651858.cd007399.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
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).
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Affiliation(s)
- Abel Wakai
- Division of Population Health Sciences (PHS), Royal College of Surgeons in Ireland (RCSI)Emergency Care Research Unit (ECRU)123 St. Stephen's GreenDublin 2Ireland
| | - Carol Blackburn
- Our Lady's Children's Hospital CrumlinDepartment of Emergency MedicineDublinIreland12
| | - Aileen McCabe
- Division of Population Health Sciences (PHS), Royal College of Surgeons in IrelandEmergency Care Research Unit (ECRU)123 St. Stephen's GreenDublin 2Ireland
| | - Emilia Reece
- Princess Alexandra HospitalDepartment of AnaesthesiaQueenslandAustralia
| | - Ger O'Connor
- Mater Misericordiae University HospitalDepartment of Emergency MedicineEccles StreetDublinIreland7
| | - John Glasheen
- Cork University HospitalDepartment of Emergency MedicineCorkIreland
| | - Paul Staunton
- St. James's HospitalDepartment of Emergency MedicineJames's StreetDublinIrelandDublin 8
| | - John Cronin
- National Children's Research Centre, Our Lady's Children's Hospital Crumlin; University College DublinPaediatric Emergency Research Unit (PERU), Department of Emergency MedicineCrumlinDublinIreland12
| | - Christopher Sampson
- University of Missouri‐ColumbiaDepartment of Emergency Medicine M5621 Hospital Drive DC029.1ColumbiaMOUSA65212
| | - Siobhan C McCoy
- Cork University HospitalDepartment of Emergency MedicineCorkIreland
| | - Ronan O'Sullivan
- Cork University HospitalCorkIreland
- Our Lady's Children's Hospital CrumlinNational Children's Research CentreDublinIreland12
| | - Fergal Cummins
- National AmbulanceDepartment of Clinical ServicesLevel 7 tower 3Etihad TowersAbu DhabiAbu DhabiUnited Arab Emirates63788
- Charles Sturt UniversityPort MacquarieNSWAustralia
- University of LimerickGraduate Entry Medical School ILimerickIreland
- REDSPoT Retrieval Emergency Disaster Medicine Research and Development UnitLimerickIreland
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11
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Lewis SR, Nicholson A, Reed SS, Kenth JJ, Alderson P, Smith AF. Anaesthetic and sedative agents used for electrical cardioversion. Cochrane Database Syst Rev 2015; 2015:CD010824. [PMID: 25803543 PMCID: PMC6353050 DOI: 10.1002/14651858.cd010824.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Electrical cardioversion is an effective procedure for restoring normal sinus rhythm in the hearts of patients with irregular heart rhythms. It is important that the patient is not fully conscious during the procedure, as it can be painful and distressing. The drug used to make patients unaware of the procedure should rapidly achieve the desired level of sedation, should wear off quickly and should not cause cardiovascular or respiratory side effects. OBJECTIVES We aimed to compare the safety, effectiveness and adverse events associated with various anaesthetic or sedative agents used in direct current cardioversion for cardiac arrhythmia in both elective and emergency settings.We sought answers to the following specific questions.• Which drugs deliver the best outcomes for patients undergoing electrical cardioversion?• Does using a particular agent confer advantages or disadvantages?• Is additional analgesic necessary to prevent pain? SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) on 27 March 2014. Our search terms were relevant to the review question and were not limited by outcomes. We also carried out searches of clinical trials registers and forward and backward citation tracking. SELECTION CRITERIA We considered all randomized controlled trials and quasi-randomized and cluster-randomized studies with adult participants undergoing electrical cardioversion procedures in the elective or emergency setting. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data, consulting with a third review author for disagreements. We used standard Cochrane methodological procedures, including assessment of risk of bias for all studies. MAIN RESULTS We included 23 studies with 1250 participants that compared one drug with one or more other drugs. Of these comparisons, 19 studies compared propofol with another drug. Seven of these compared propofol with etomidate (four of which combined the drugs with remifentanil or fentanyl), five midazolam, six thiopentone and two sevoflurane. Three studies compared etomidate with thiopentone, and three etomidate with midazolam. Two studies compared thiopentone with midazolam, one thiopentone with diazepam and one midazolam with diazepam. Drug doses and the time over which the drugs were given varied between studies. Although all studies were described as randomized, limited information was provided about the methods used for selection and group allocation. A high level of performance bias was observed across studies, as study authors had not attempted to blind the anaesthetist to group allocation. Similarly, study authors had rarely provided sufficient information on whether outcome assessors had been blinded.Included studies presented outcome data for hypotension, apnoea, participant recall, success of cardioversion, minor adverse events of nausea and vomiting, pain at injection site and myoclonus, additional analgesia and participant satisfaction. We did not pool the data from different studies in view of the multiple drug comparisons, differences in definitions and reporting of outcomes, variability of endpoints and high or unclear risk of bias across studies. AUTHORS' CONCLUSIONS Few studies reported statistically significant results for our relevant outcomes, and most study authors concluded that both, or all, agents compared in individual studies were adequate for cardioversion procedures. It is our opinion that at present, there is no evidence to suggest that current anaesthetic practice for cardioversion should change.
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Affiliation(s)
- Sharon R Lewis
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Amanda Nicholson
- c/o Cochrane Anaesthesia, Critical and Emergency Care GroupHerlevDenmark
| | - Stephanie S Reed
- Royal Lancaster InfirmaryDepartment of AnaesthesiaAshton RoadLancasterLancashireUKLA1 4RP
| | - Johnny J Kenth
- Royal Lancaster InfirmaryDepartment of AnaesthesiaAshton RoadLancasterLancashireUKLA1 4RP
| | - Phil Alderson
- National Institute for Health and Care ExcellenceLevel 1A, City Tower,Piccadilly PlazaManchesterUKM1 4BD
| | - Andrew F Smith
- Royal Lancaster InfirmaryDepartment of AnaesthesiaAshton RoadLancasterLancashireUKLA1 4RP
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Hohl CM, Nosyk B, Sadatsafavi M, Anis AH. A cost-effectiveness analysis of propofol versus midazolam for procedural sedation in the emergency department. Acad Emerg Med 2008; 15:32-9. [PMID: 18211311 DOI: 10.1111/j.1553-2712.2007.00023.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- Corinne Michèle Hohl
- Division of Emergency Medicine, Department of Surgery, University of British Columbia, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada.
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Hohl CM, Sadatsafavi M, Nosyk B, Anis AH. Safety and clinical effectiveness of midazolam versus propofol for procedural sedation in the emergency department: a systematic review. Acad Emerg Med 2008; 15:1-8. [PMID: 18211306 DOI: 10.1111/j.1553-2712.2007.00022.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To synthesize the evidence comparing the adverse event (AE) profile and clinical effectiveness of midazolam and propofol for procedural sedation (PS) in adults in the emergency care setting. METHODS The authors conducted a systematic review of randomized controlled trials (RCTs) and observational studies reporting the use of either midazolam and/or propofol for adult PS in the emergency department (ED). A systematic search strategy was developed and applied to six bibliographic reference databases. Three emergency medicine journals, the Canadian Adverse Drug Reaction Newsletter, and conference proceedings were hand-searched. Retrieved articles were reviewed and data were abstracted using standardized data collection. Trial quality was assessed using the Jadad score. The outcomes assessed were the proportion of patients with AEs and the pooled mean difference in the proportion of patients with successful PS. RESULTS Of 229 articles identified, 28 met the inclusion criteria for the analysis of AEs. Only one major AE to PS was found, resulting in no statistically significant difference in the proportion of major AEs between agents. Four studies were RCTs that met the inclusion criteria for the analysis of clinical effectiveness. Two trials met criteria for good quality. The RCTs enrolled between 32 and 86 patients, and the most common indications for PS were orthopedic reductions and cardioversions. There was a nonsignificant difference in the proportion of patients with successful PS in favor of propofol (effect difference 2.9%, 95% confidence interval (CI) = -6.5 to 15.2). CONCLUSIONS The authors found no significant difference in the safety profile and the proportion of successful PS between midazolam and propofol for adults in the ED.
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Affiliation(s)
- Corinne Michèle Hohl
- Division of Emergency Medicine, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada.
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15
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Current World Literature. Curr Opin Anaesthesiol 2007; 20:388-94. [PMID: 17620851 DOI: 10.1097/aco.0b013e3282c3a878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Current World Literature. Curr Opin Anaesthesiol 2007; 20:284-6. [PMID: 17479036 DOI: 10.1097/aco.0b013e3281e3380b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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