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Adinehmehr L, Shetabi H, Moradi Farsani D, Salehi A, Noorbakhsh M. Comparison of the Sedation Quality of Etomidate, Propofol, and Midazolam in Combination with Fentanyl During Phacoemulsification Cataract Surgery: A Double-Blind, Randomized, Controlled, Clinical Trial. Anesth Pain Med 2019; 9:e87415. [PMID: 31341824 PMCID: PMC6616865 DOI: 10.5812/aapm.87415] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 03/23/2019] [Accepted: 03/28/2019] [Indexed: 02/06/2023] Open
Abstract
Background According to the favorable effects of combination therapy to provide better sedation during phacoemulsification and lack of any studies investigating the sedative effect of etomidate, propofol, and midazolam in combination with fentanyl during the procedure. Objectives The current study aimed at comparing the sedative properties of the mentioned three combination therapies in this field. Methods The current double-blind, randomized, controlled clinical trial was conducted on patients referred for elective phacoemulsification surgery under sedation. They were randomly allocated to the three groups to receive fentanyl plus one of the following medications: Propofol, midazolam, and etomidate. Demographic characteristics, medical condition, and hemodynamic parameters before, during, and after surgery, sedation level, anesthetic complications, sedation-related adverse events, and patients' and surgeons' satisfaction were evaluated and recorded by the anesthesiologist and compared in the three studied groups. Results In the current study, out of 150 enrolled patients, 98 completed the study. Frequency of different levels of Ramsay scores was not significantly different between the groups (P = 0.41). Frequency of Ramsay scores 3 and 4 was 92%, 79.4%, and 88.2% in etomidate, midazolam and propofol groups, respectively (P = 0.32). The median recovery time was significantly higher in the midazolam group than the propofol group (P = 0.04); intergroup comparisons indicated that the patients' mean score of satisfaction in the propofol group was significantly higher than that of the etomidate group (P = 0.006). Conclusions The current study findings indicated that though the quality of sedation during phacoemulsification cataract surgery was acceptable in the three agents and the results had no significantly differences among the groups, and considering other factors including recovery time, hemodynamic evaluation, sedation-related complications, and patients' satisfication scores, it is suggested that propofol was superior to the other two agents.
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Affiliation(s)
- Leili Adinehmehr
- Anesthesiology and Critical Care Department, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hamidreza Shetabi
- Anesthesiology and Critical Care Department, Isfahan University of Medical Sciences, Isfahan, Iran
- Corresponding Author: Anesthesiology Department, Al Zahra Medical Center, Isfahan University of Medical Sciences, Sofeh Blvd., Isfahan, Iran.
| | - Darioush Moradi Farsani
- Anesthesiology and Critical Care Department, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ali Salehi
- Ophthalmology Department, Isfahan University of Medical Sciences, Isfahan, Iran
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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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Qin B, Hu H, Cao B, Zhu Z. Effects of continuous infusion of etomidate at various dose rates on adrenal function in dogs. BMC Anesthesiol 2016; 16:2. [PMID: 26743223 PMCID: PMC4705599 DOI: 10.1186/s12871-015-0171-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 12/30/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Etomidate is a commonly used sedative in intravenous anesthesia. The aim of this study was to compare the effects of various etomidate doses administered by continuous infusion on adrenal function in dogs under general anesthesia. METHODS Thirty-six healthy adult male dogs were randomly divided into six groups. Sodium pentobarbital alone was administered to the control group (group C); five experimental groups (E1, E2, E3, E4, and E5) were also given etomidate at doses of 10, 15, 20, 25, and 30 μg · kg(-1) · min(-1), respectively, to maintain anesthesia. Heart rate (HR), mean arterial pressure (MAP), and bispectral index (BIS) were monitored. Serum cortisol, aldosterone, adrenaline, and noradrenaline levels were measured, and HR, MAP, and BIS values recorded, before intubation (T0), and at 1 h, 2 h, and 3 h after intubation (T1-3). RESULTS Cortisol and aldosterone levels in groups E1-5 decreased as the doses and times of continuous infusion of etomidate increased. The cortisol level was significantly decreased compared with baseline at T3 in group E1 and at T1-3 in groups E2-5 (P < 0.05). Compared with the corresponding levels in group C, cortisol levels were significantly lower than T0 values at T3 in group E1 and at T1-3 in groups E2-5 (P < 0.05). The aldosterone level was significantly lower at T3 in group E2 and at T1-3 in groups E3-5 (P < 0.05). Significant reductions in cortisol levels at T2-3 in group E2 and at T1-3 in groups E3-5 compared with group C were also observed (P < 0.05). The plasma adrenaline and noradrenaline levels, HR, MAP, and BIS in groups E1-5 were within the normal range at the different times and with the different doses (P > 0.05). CONCLUSIONS Cortisol and aldosterone levels decreased with time and continuous infusion of etomidate; there were no significant changes in adrenaline and noradrenaline levels, HR, MAP, and BIS in any group.
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Affiliation(s)
- Bangyong Qin
- Department of Anesthesiology, Affliated Hospital of Zunyi Medical College, No. 149 Dalian Road, Zunyi, Guizhou Province, 563003, China.
| | - Hongzhuan Hu
- Department of Anesthesiology, Affliated Hospital of Zunyi Medical College, No. 149 Dalian Road, Zunyi, Guizhou Province, 563003, China
| | - Baofeng Cao
- Department of Anesthesiology, Affliated Hospital of Zunyi Medical College, No. 149 Dalian Road, Zunyi, Guizhou Province, 563003, China
| | - Zhaoqiong Zhu
- Department of Anesthesiology, Affliated Hospital of Zunyi Medical College, No. 149 Dalian Road, Zunyi, Guizhou Province, 563003, China
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Abstract
Etomidate is an intravenous anesthetic agent released for clinical use in the United States in 1972. Its popularity in clinical practice is the result of its beneficial effects on intracerebral dynamics with limited effects on hemodynamic function. These properties have made it a safe and effective anesthetic induction agent in both adult and pediatric patients with altered myocardial performance, congenial heart disease, or hypovolemia. However, recent concern has been expressed regarding its effects on the endogenous production of corticosteroids and the impact of that effect on patient outcomes. The following manuscript reviews clinical reports regarding etomidate use in the pediatric population and discusses recent concerns regarding its effects on corticosteroid metabolism and the implications of such effects for clinical use.
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Affiliation(s)
- Joseph D. Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Anesthesiology and Pain Medicine, Columbus, Ohio, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Jacques KG, Dewar A, Gray A, Kerslake D, Leal A, Open M. Procedural sedation and analgesia in the emergency department. TRAUMA-ENGLAND 2015. [DOI: 10.1177/1460408614539625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Keith G Jacques
- Emergency Department, Forth Valley Royal Hospital, Larbert, UK
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Wang X, Jin A, An M, Ding Y, Tuo Y, Qiu Y. Etomidate deteriorates the toxicity of advanced glycation end products to human endothelial Eahy926 cells. J Toxicol Sci 2014; 39:887-96. [PMID: 25421967 DOI: 10.2131/jts.39.887] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Affiliation(s)
- Xiaodong Wang
- Department of Anesthesiology, Second Affiliated Hospital of Inner Mongolia Medical University, China
| | - Arong Jin
- Department of Hematology, Inner Mongolia People’s Hospital, China
| | - Min An
- Department of Anesthesiology, Second Affiliated Hospital of Inner Mongolia Medical University, China
| | - Yumei Ding
- Department of Anesthesiology, Second Affiliated Hospital of Inner Mongolia Medical University, China
| | - Ya Tuo
- Department of Anesthesiology, Second Affiliated Hospital of Inner Mongolia Medical University, China
| | - Yi Qiu
- Department of Anesthesiology, Second Affiliated Hospital of Inner Mongolia Medical University, China
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A descriptive study of myoclonus associated with etomidate procedural sedation in the ED. Am J Emerg Med 2013; 31:852-4. [PMID: 23558062 DOI: 10.1016/j.ajem.2013.02.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2013] [Revised: 02/26/2013] [Accepted: 02/27/2013] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Myoclonus is a well-recognized side effect of etomidate when given in induction doses for rapid sequence intubation. Most of the data reported on myoclonus with emergency department (ED) sedation doses are reported as a secondary finding. STUDY OBJECTIVES Our objective was to prospectively quantify the incidence and duration of myoclonus associated with the administration of etomidate in the lower doses given for procedural sedation in the ED. METHODS This was a prospective descriptive study performed between September 2008 and September 2010 at an urban teaching hospital ED with approximately 50000 patient visits per year. Procedural sedation was performed at the discretion of the treating emergency physician, and adult patients receiving etomidate were eligible for enrollment. The occurrence and duration of myoclonus were observed and recorded. Any interference of myoclonus with the ability to complete the procedure was recorded, and adverse effects were identified. RESULTS Thirty-four eligible subjects were enrolled, and 36 separate sedation procedures were performed. The mean initial etomidate dose was 0.13 mg/kg (range, 0.077-0.20), and the mean total etomidate dose was 0.15 mg/kg (range, 0.077-0.29). Myoclonus was noted in 26 (72%) of 36 sedations. Mean time to onset of myoclonus was 50 seconds (range, 15-146), and the mean duration was 93 seconds (range, 03-557). Myoclonus interfered with the procedure in only 1 (3%) of 36 attempted procedures, and no procedure was unsuccessful because of myoclonus. CONCLUSION Myoclonus associated with sedation doses of etomidate was common but rarely interfered with the completion of a procedure.
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Arlachov Y, Ganatra RH. Sedation/anaesthesia in paediatric radiology. Br J Radiol 2012; 85:e1018-31. [PMID: 22898157 PMCID: PMC3500799 DOI: 10.1259/bjr/28871143] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Revised: 03/17/2012] [Accepted: 04/02/2012] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES In this article we will give a comprehensive literature review on sedation/general anaesthesia (S/GA) and discuss the international variations in practice and options available for S/GA for imaging children. METHODS The key articles were obtained primarily from PubMed, MEDLINE, ERIC, NHS Evidence and The Cochrane Library. RESULTS Recently, paediatric radiology has seen a surge of diagnostic and therapeutic procedures, some of which require children to be still and compliant for up to 1 h. It is difficult and sometimes even impossible to obtain quick and high-quality images without employing sedating techniques in certain children. As with any medical procedure, S/GA in radiological practice is not without risks and can have potentially disastrous consequences if mismanaged. In order to reduce any complications and practice safety in radiological units, it is imperative to carry out pre-sedation assessments of children, obtain parental/guardian consent, monitor them closely before, during and after the procedure and have adequate equipment, a safe environment and a well-trained personnel. CONCLUSION Although the S/GA techniques, sedative drugs and personnel involved vary from country to country, the ultimate goal of S/GA in radiology remains the same; namely, to provide safety and comfort for the patients. Advances in knowledge Imaging children under general anaesthesia is becoming routine and preferred by operators because it ensures patient conformity and provides a more controlled environment.
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Affiliation(s)
- Y Arlachov
- Nottingham University Hospitals NHS Trust-Queen's Medical Centre Campus, Nottingham, UK.
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Denny MA, Manson R, Della-Giustina D. Propofol and Etomidate are Safe for Deep Sedation in the Emergency Department. West J Emerg Med 2012; 12:399-403. [PMID: 22224127 PMCID: PMC3236171 DOI: 10.5811/westjem.2011.5.2099] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Revised: 12/23/2010] [Accepted: 05/02/2011] [Indexed: 11/11/2022] Open
Abstract
This study describes deep sedations performed for painful procedures completed in the emergency department at an academic tertiary care hospital during an 18-month period. One hundred consecutive cases were retrospectively reviewed to describe indications, complications, procedural lengths, medication dosing, and safety of these sedations. Propofol and etomidate were the preferred agents. We found that there were relatively few complications (10%), with only 2 of these (2%) being major complications. All complications were brief and did not adversely affect patient outcomes. This data further demonstrate the safety profile of deep sedation medications in the hands of emergency physicians trained in sedation and advanced airway techniques.
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Affiliation(s)
- Mark A Denny
- Diley Ridge Medical Center, Canal Winchester, Ohio
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10
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Etomidate for procedural sedation in the elderly: a retrospective comparison between age groups. Am J Emerg Med 2011; 29:1111-6. [DOI: 10.1016/j.ajem.2010.08.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2010] [Revised: 08/16/2010] [Accepted: 08/19/2010] [Indexed: 11/21/2022] Open
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Welliver M, Bednarzyk M. Sedation considerations for the nonintubated obese patient in critical care. Crit Care Nurs Clin North Am 2011; 21:341-52, vi. [PMID: 19840713 DOI: 10.1016/j.ccell.2009.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Sedation of the obese critical care patient presents unique challenges that include altered respiratory function and a predisposition to respiratory suppression and airway obstruction. Sedative drugs have pronounced effects on obese patients. Knowledge of the anatomic and physiologic changes associated with obesity, airway management, and sedation agents better prepares one to care for these patients safely and effectively.
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Affiliation(s)
- Mark Welliver
- School of Nurse Anesthesia, Harris College of Nursing and Health Sciences, Texas Christian University, Fort Worth, TX 76109, USA.
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12
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Nestor NB, Burton JH. ED use of etomidate for rapid sequence induction. Am J Emerg Med 2008; 26:946-50. [DOI: 10.1016/j.ajem.2007.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2007] [Revised: 12/04/2007] [Accepted: 12/05/2007] [Indexed: 11/15/2022] Open
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Miner JR, Martel ML, Meyer M, Reardon R, Biros MH. Procedural Sedation of Critically Ill Patients in the Emergency Department. Acad Emerg Med 2008. [DOI: 10.1111/j.1553-2712.2005.tb00847.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Miner JR, Danahy M, Moch A, Biros M. Randomized Clinical Trial of Etomidate Versus Propofol for Procedural Sedation in the Emergency Department. Ann Emerg Med 2007; 49:15-22. [PMID: 16997421 DOI: 10.1016/j.annemergmed.2006.06.042] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2006] [Revised: 06/14/2006] [Accepted: 06/29/2006] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE We compare the efficacy, adverse events, and recovery duration of etomidate and propofol for use in procedural sedation in the emergency department (ED). METHODS This was a randomized nonblinded prospective trial of adult patients undergoing procedural sedation for painful procedures in the ED. Patients received either propofol or etomidate. Doses, vital signs, nasal end-tidal CO2 (ETCO2), pulse oximetry, and bispectral electroencephalogram analysis scores were recorded. Subclinical respiratory depression was defined as a change in ETCO2 greater than 10 mm Hg, an oxygen saturation of less than 92% at any time, or an absent ETCO2 waveform at any time. Clinical events related to respiratory depression, including an increase in supplemental oxygen, the use of a bag-valve-mask apparatus, airway repositioning, or stimulation to induce breathing, were noted during the procedure. After the procedure, patients completed visual analog scales about perceived pain during the procedure and recall of the procedure. RESULTS Two hundred twenty patients were enrolled; 214 underwent sedation and were analyzed. One hundred five patients received etomidate and 109 received propofol. No clinically significant complications were noted. Subclinical respiratory depression was observed in 36 of 105 (34.3%) patients in the etomidate group and 46 of 109 (42.2%) in the propofol group (difference -7.9%; 95% confidence interval [CI] -20.9% to 5.1%). Myoclonus was noted in 21 of 105 (20.0%) patients in the etomidate group and 2 of 109 (1.8%) in the propofol group (difference 18.2%; 95% CI 10.1% to 26.2%). The mean difference between baseline systolic blood pressure and the nadir was 3.8% (95% CI 2.3% to 5.3%) for etomidate and 7.9% (95% CI 6.1% to 9.7%) for propofol. Clinical events related to respiratory depression included an increase in supplemental oxygen in 6.7% of etomidate patients and 5.5% of propofol patients (difference 1.2%; 95% CI -5.2% to 7.6%), the use of bag-valve-mask apparatus in 3.8% of patients in the etomidate groups and 4.6% in the propofol group (difference -0.8%; 95% CI -6.1% to 4.6%), airway repositioning in 13.3% of etomidate patients and 11.0% of propofol patients (effect size 2.3%; 95% CI -6.4% to 11.1%), and stimulation to induce breathing in 11.4% of etomidate patients and 11.9% of propofol patients (difference -0.5%; 95% CI -9.1% to 8.1%). The procedures were successful in 93 of 105 (88.6%) for etomidate and 106 of 109 (97.2%) for propofol (difference -7.4%; 95% CI -14.3% to -1.1%). CONCLUSION Etomidate and propofol appear equally safe for ED procedural sedation; however, etomidate had a lower rate of procedural success and induced myoclonus in 20% of patients.
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Affiliation(s)
- James R Miner
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN 55415, USA.
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15
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Green SM. Research Advances in Procedural Sedation and Analgesia. Ann Emerg Med 2007; 49:31-6. [PMID: 17083997 DOI: 10.1016/j.annemergmed.2006.09.020] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2006] [Revised: 09/11/2006] [Accepted: 09/20/2006] [Indexed: 11/18/2022]
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Abstract
Procedural sedation and analgesia has become a commonplace procedure in the ED, certainly falling under the domain of the EP. Every EP should approach PSA as a complex procedure requiring high-level skills and knowledge. Initially, understand that PSA represents a spectrum of goals, from anxiolysis and pain relief to deep sedation. Assess the needs of the patient and the concomitant procedure and set goals accordingly. There is a pharmacopia of drugs that provide sedation and analgesia. Become familiar with their pharmacology, advantages and disadvantages, and indications. This will allow for appropriate usage and achievement of sedation goals. Several drugs that are commonly used for general anesthesia are proving themselves to be safe and efficacious for PSA. Both etomidate and propofol have emerged as useful drugs for PSA. Continued research and practice with these agents will add to our understanding and help define their use for PSA. Performing PSA as a procedure itself requires preparedness, diligent monitoring, and risk awareness. Knowing the patient's comorbid state and choosing agents that will not exacerbate their baseline status minimize risk. Following fasting guidelines is appropriate in certain clinical situations, and is prudent when time permits. However, these guidelines are a benchmark for minimizing risk and are not supported by evidence-based medicine. It is important to be cognizant of the guidelines but also to identify the emergency scenario where action must be taken despite the fasting guidelines. Controlling sedation depth also minimizes the risk of aspiration and other complications. The ETCO2 monitor and Bispectral Index may prove to be useful adjuncts for monitoring sedation depth. However, there is nothing yet that measures sedation depth quantitatively that can replace the qualitative assessment of the EP. More and more PSA is falling under the domain of the EP. It is important for the EP to be involved in hospital policy and guidelines associated with this procedure, and to remain aware of new research in this field. EPs can thereby contribute to quality assurance throughout the medical community by setting a standard in the practice of PSA, as they are not the only practitioners using this procedure. With continued practice and research, expertise in this field will grow measurably.
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Affiliation(s)
- Elizabeth L Bahn
- Department of Emergency Medicine, Madigan Army Medical Center, Fort Lewis, WA 984431, USA.
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Godwin SA, Caro DA, Wolf SJ, Jagoda AS, Charles R, Marett BE, Moore J. Clinical policy: Procedural sedation and analgesia in the emergency department. Ann Emerg Med 2005; 45:177-96. [PMID: 15671976 DOI: 10.1016/j.annemergmed.2004.11.002] [Citation(s) in RCA: 167] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
Sedating children for diagnostic and therapeutic procedures remains an area of rapid change and considerable controversy. Exploration of this topic is made difficult by the fact that the reports of techniques and outcomes for pediatric sedation appear in a wide range of subspecialty publications and rarely undergo comprehensive examination. In this review article, we will touch on many aspects of the topic of pediatric sedation from the perspective of the anesthesiologist. We begin with a review of the historical role of anesthesiologists in the development of the current standards for pediatric sedation. We also examine the current status of pediatric sedation as reflected in published studies and reports. A specific review of the issues surrounding safety of sedation services is included. Current trends in sedation practice, including the expanding role of potent sedative hypnotic drugs outside the field of anesthesiology, are noted. Finally, we suggest future areas for research and clinical improvement for sedation providers.
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Affiliation(s)
- Joseph P Cravero
- Department of Anesthesiology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
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Mace SE, Barata IA, Cravero JP, Dalsey WC, Godwin SA, Kennedy RM, Malley KC, Moss RL, Sacchetti AD, Warden CR, Wears RL. Clinical policy: evidence-based approach to pharmacologic agents used in pediatric sedation and analgesia in the emergency department. J Pediatr Surg 2004; 39:1472-84. [PMID: 15486890 DOI: 10.1016/j.jpedsurg.2004.07.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Mace SE, Barata IA, Cravero JP, Dalsey WC, Godwin SA, Kennedy RM, Malley KC, Moss RL, Sacchetti AD, Warden CR, Wears RL. Clinical Policy: Evidence-based Approach to Pharmacologic Agents Used in Pediatric Sedation and Analgesia in the Emergency Department. J Emerg Nurs 2004; 30:447-61. [PMID: 15452523 DOI: 10.1016/j.jen.2004.07.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
OBJECTIVE To review the current efficacy and safety evidence for the use of etomidate for procedural sedation in the emergency department (ED). DATA SOURCES MEDLINE (1966-December 2003), EMBASE (1980-December 2003), PubMED (1966-December 2003), and Cochrane Database of Systemic Reviews (up to December 2003) were searched for full-text reports published in English on the use of etomidate in humans. Search terms included etomidate, procedural sedation, conscious sedation, relocation, dislocation, abscess incision, abscess drainage, and cardioversion. STUDY SELECTION AND DATA EXTRACTION Prospective and retrospective studies evaluating efficacy or safety endpoints using etomidate for procedural sedation in the ED were included. All studies were evaluated independently by both authors. For clinical outcomes (efficacy, safety), the definitions specified by each study were used. DATA SYNTHESIS Three observational studies and 5 prospective, randomized controlled trials were included in this review. Onset of action and time to recovery following etomidate were rapid and found to be comparable to that of propofol and thiopental but significantly faster than that of midazolam. The dose of etomidate for procedural sedation ranged from 0.15 to 0.22 mg/kg. No significant hemodynamic effects were observed; however, respiratory depression resulting in oxygen desaturation to <90% or apnea appears to occur in approximately 10% of patients undergoing procedural sedation with etomidate with or without analgesia. The most prominent adverse effect reported with etomidate was myoclonus, occurring in 20-45% of patients. CONCLUSIONS Etomidate is an appropriate and valuable agent for performing procedural sedation in the ED. The rapid onset and recovery time and relative lack of significant hemodynamic and respiratory effects may facilitate optimal and safe conditions for procedural sedation in the ED.
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Affiliation(s)
- Jamie Falk
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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Kramer DC, Grass G. Challenges facing the anesthesiologist in the emergency department. Curr Opin Anaesthesiol 2003; 16:409-16. [PMID: 17021490 DOI: 10.1097/01.aco.0000084474.59960.49] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review focuses on developments in airway management and concious sedation/analgesic techniques employed by anesthesiologists in the emergency department. RECENT FINDINGS Emergency medicine physicians routinely employ airway devices and techniques that were previously reserved for anesthesiologists. An understanding of the uses and limitations of these devices are essential for successful outcomes. Anesthesiologists responding to the emergency department may be faced with soiled or traumatized airways. The use of newer devices in cervical trauma and the difficult airway is reviewed. Consious sedation in the emergency department is also reviewed. There are no published recommendations demonstrating the advantage of specific agents for sedation in the emergency department. A wide variety of medications and techniques are currently being employed. Studies indicate that the incidence of adverse effects from these agents range from less than 1% to almost 30%. Various organizations have published guidelines detailing the appropriate protocols and equipment that must be present in the emergency department to monitor patients undergoing conscious sedation. These recommendations have not been universally implemented, and several recent studies suggest that a substantial number of emergency departments may have major deficiencies. SUMMARY The consultant anesthesiologist responding to a critical airway may face a variety of challenges, including traumatized or soiled airways, patients with cervical spine fractures, and patients who have undergone sedation techniques that may have progressed to deep and general anesthesia. Anesthesiologists may also face the challenge of responding to these emergent situations without all the equipment or adequately trained support staff necessary to handle those emergencies safely.
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Affiliation(s)
- David C Kramer
- Department of Anesthesiology, Mount Sinai Medical Center, New York, New York 10029-6574, USA
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Kramer D, Grass G. Curr Opin Anaesthesiol 2003; 16:409-416. [DOI: 10.1097/00001503-200308000-00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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