Procedural sedation in the emergency department

Comparing the Safety and Effectiveness of Ketamine Versus Benzodiazepine/Opioid Combination for Procedural Sedation in Emergency Medicine: A Comprehensive Review and Meta-Analysis

Procedural sedation is essential in the ED to conduct painful procedures effectively. Ketamine and benzodiazepines/opioids are commonly used, with ketamine providing adequate analgesia and preserving airway muscle tone. However, ketamine is associated with adverse effects while benzodiazepines/opioids can lead to respiratory depression. This study compares the safety and efficacy of ketamine and midazolam/fentanyl. Two search methods were used to identify studies related to our topic, including a database search and a manual search involving screening reference lists of articles retrieved by the database search. A methodological quality appraisal was conducted on the articles suitable for inclusion using Cochrane's risk of bias tool in the Review Manager software (Review Manager (RevMan) (Computer program). Version 5.4, The Cochrane Collaboration, 2020). Moreover, pooled analysis was performed using the Review manager software. The study analyzed 1366 articles, of which seven were included for analysis. Pooled data showed that ketamine and midazolam/fentanyl had similar effects on pain scores during procedures and sedation depth measured by the University of Michigan sedation scale. However, the Modified Ramsay Sedation Score showed significantly more profound sedation in the ketamine group. The only significant adverse events were vomiting and nausea, which had a higher incidence in the ketamine group. Our data suggest that ketamine is as effective as the midazolam/fentanyl combination for procedural sedation but is associated with higher incidences of adverse events. Therefore, midazolam/fentanyl can be recommended for procedural sedation in the ED. However, it should be provided in the presence of a physician comfortable with airway management due to high incidences of oxygen desaturation.

Ketamine-propofol (Ketofol) for procedural sedation and analgesia in children: a systematic review and meta-analysis

Objectives

The aim of this review is to elucidate the efficacy and side effects of ketofol in comparison to other anaesthetic agents during procedural sedation and analgesia.

Method

The Cochrane Central Register of Controlled Trials (1996 to Feb 2019) and MEDLINE (1966 to Feb 2019) were searched, including the related randomised control trials and reviewed articles to find unpublished trials or trials not obtained via electronic searches. Inclusion criteria for the studies included comparing recovery time, recording clinician satisfaction, and assessing the adverse effects of ketofol.

Results

Eleven trials consisting of a total of 1274 patients met our criteria and were included in this meta-analysis. Five trials compared ketofol with a single agent, while six trials compared ketofol with combined agents. While comparing between ketofol and a single agent (either ketamine or propofol), ketofol showed significant effect on recovery time (MD: -9.88, 95% CI: − 14.30 to − 5.46; P = 0.0003; I² = 92%). However, no significant difference was observed while comparing ketofol with combined agents (RR: 0.75, 95% CI: − 6.24 to 7.74; P < 0.001; I² = 98%). During single-agent comparison, ketofol showed no significant differences in terms of clinician satisfaction (RR: 2.86, 95% CI: 0.64 to 12.69; P = 0.001; I² = 90%), airway obstruction (RR: 0.72, 95% CI: 0.35 to 11.48; P = 0.81; I² = 0%), apnoea (RR: 0.9, 95% CI: 0.33 to 2.44; P = 0.88; I² = 0%), desaturation (RR: 1.11, 95% CI: 0.64 to 1.94; P = 0.28; I² = 21%), nausea (RR: 0.52, 95% CI: 0.91 to 1.41; P = 0.2; I² = 38%), and vomiting (RR: 0.63, 95% CI: 0.25 to 1.61; P = 0.18; I² = 42%). During comparison with combined agents, ketofol was more effective in reducing hypotension (RR: 4.2, 95% CI: 0.2 to 0.85; P = 0.76; I² = 0%), but no differences were observed in terms of bradycardia (RR: 0.70, 95% CI: 0.14 to 03.63; P = 0.09; I² = 53%), desaturation (RR: 1.9, 95% CI: 0.15 to 23.6; P = 0.11; I² = 61%), and respiratory depression (RR: 1.98, 95% CI: 0.18 to 21.94; P = 0.12; I² = 59%).

Conclusion

There is low certainty of evidence that ketofol improves recovery time and moderate certainty of evidence that it reduces the frequency of hypotension. There was no significant difference in terms of other adverse effects when compared to other either single or combined agents.

Trial registration

PROSPERO CRD42019127278.

Conscious sedation and reduction of fractures in the paediatric population: an orthopaedic perspective

PURPOSE

Closed reduction under conscious sedation in the emergency department (ED) has been demonstrated to provide cost-effective, timely care. There has been little research into the efficacy of conscious sedation and reduction from an orthopaedic trauma perspective. This study describes the epidemiology and outcomes associated with fracture conscious sedation and reduction in our level I paediatric ED.

METHODS

All fracture patients presenting overnight to our level I trauma centre ED between 01 June 2016 and 30 June 2017 were identified. Patient records were reviewed to determine diagnoses, treatments and outcomes. The rate of repeat intervention after successful conscious sedation and reduction and rate of changes in management in which the orthopaedic resident's overnight management plan to provide procedural sedation was altered to surgical intervention after morning case review rounds was calculated.

RESULTS

Conscious sedation and reduction was performed on a total of 386 patients covering ten fracture types during the course of our study, with distal radius fractures (n = 167, 43.3%) comprising the majority of cases. A total of 53 cases (13.7%, 53/386) lost alignment and required repeat intervention, consisting of 33 cases (8.5%, 33/386) that required repeat surgery and 5.2% (20/386) that required cast wedging. In all, 12 patients (3.1%, 12/386) initially reduced under conscious sedation required a change in management and surgical intervention. There were five cases of growth arrest and two cases of malunion.

CONCLUSIONS

Conscious sedation and reduction provides an alternative to general anaesthesia for many paediatric trauma injuries without compromising patient outcomes.

LEVEL OF EVIDENCE

IV.

Procedural sedation and analgesia practices in the emergency centre

Introduction

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

Methods

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

Results

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

Conclusion

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

Procedural sedation in non-intubated children with severe trauma - A single center study

BACKGROUND

Non-intubated children frequently undergo emergent procedures in the trauma-bay. This study evaluates whether patients treated with procedural sedation have an increased risk for severe adverse events.

METHODS

Retrospective analysis of 1182 children with an injury severity score (ISS) of greater than 15.

RESULTS

Of the 565 patients who were spontaneously breathing on arrival, 455 were hemodynamically stable with a Glasgow Coma Score of 15, 201 of whom were treated with sedation; 144 (71.6%) had computerized tomography scan, 35 (17.5%) wound debridement, and 22 (10.9%) fracture reduction. Sedation patients had an ISS of 20 (interquartile range 17-25). There were no death cases, no cases of cardiopulmonary resuscitation, and no cases of neurologic sequelae on hospital discharge. There were 2 (1%) cases of unanticipated endotracheal intubation.

CONCLUSIONS

Non-intubated patients who were hemodynamically stable with a Glasgow Coma Score of 15 had a low risk for severe adverse events due to sedation.

Case Report: Ultrasound-Guided Infraclavicular Brachial Plexus Block for a Case with Posterior Elbow Dislocation

BACKGROUND

The interest in regional anesthesia procedures for the management of upper-extremity emergencies has increased. Toward that end, supraclavicular, interscalene, or infraclavicular approaches, with or without ultrasound guidance, are used for brachial plexus nerve blocks. Although many studies have reported on the use of ultrasound-guided supraclavicular and interscalene brachial plexus blocks for upper-extremity dislocations, very few studies have reported on the use of ultrasound-guided infraclavicular brachial plexus blocks.

CASE REPORT

We present an adult patient with posterior elbow dislocation that is treated with reduction after applying an ultrasound-guided infraclavicular brachial plexus block. Additionally, we describe the infraclavicular block in detail and demonstrate the technique using images. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Based on our experience, the ultrasound-guided infraclavicular block is a fast, safe, and efficient anesthesia technique that can be an excellent alternative to sedoanalgesia and other brachial plexus blocks for the management of elbow dislocations in the emergency department.