Abstract
BackgroundProcedural sedation is a core skill of the emergency physician. Bolus administration of propofol is widely utilised in UK emergency departments to provide procedural sedation. Bolus administration of propofol, titrated to an endpoint of sedation, has a rapid effect but can easily result in apnoea and loss of airway patency. The use of a target-controlled infusion of propofol allows for controlled titration to an effect site concentration and may reduce the rate of adverse incidents. Target-controlled infusion of propofol is not currently used in emergency departments.The primary aim of this feasibility study is to ensure that propofol target-controlled infusion (TCI) is acceptable to the patient and that recruitment rates are adequate to power a randomised controlled trial comparing propofol target-controlled infusion versus bolus administration.MethodsThis study will recruit in four emergency departments in Scotland, UK. Patients aged 18–65 years with anterior shoulder dislocation, weighing ≥ 50 kg and fasted ≥ 90 min, will be screened. Recruited patients will undergo emergency reduction of a dislocated shoulder facilitated by procedural sedation utilising TCI of propofol.The widespread adoption of TCI propofol by emergency departments will require evidence that it is safe, potentially effective, patient centred and a timely method of providing procedural sedation. The primary endpoint will be acceptability measured by patient satisfaction. The secondary endpoints will include incidence and severity of adverse events, number of shoulder reduction attempts, nursing opinion of patient experience, patient’s reported pain score and time from commencement of TCI propofol sedation to desired sedation level.The study will be open for recruitment from April 2017 to December 2018.DiscussionIf the study demonstrates patient acceptability with adequate recruitment, we will be in a position to determine the feasibility of progression to a randomised controlled clinical trial of TCI compared to bolus administration of propofol.Trial registrationClinicalTrials.gov Identifier: NCT03442803. Registered retrospectively on 22 February 2018.
Highlights
Procedural sedation is a core skill of the emergency physician
Sedation in the emergency department Procedural sedation and analgesia (PSA) has long been a core skill of the emergency physician, over the last decade, developments in patient monitoring and the use of newer sedative and analgesic agents have served to improve both safety and efficacy [1]. Despite these advances and their consolidation into well-designed guidelines [2, 3], concern regarding the safety of emergency department (ED) PSA persists [4, 5]
Despite being a relatively short-lived effect, this may be pronounced in those with intravascular volume depletion [13] or in the elderly [14], and in some may be profound, with one series demonstrating that 3.5% of those undergoing PSA with propofol experience ≥ 20% falls in blood pressure [15]
Summary
Procedural sedation is a core skill of the emergency physician. Bolus administration of propofol is widely utilised in UK emergency departments to provide procedural sedation. Sedation in the emergency department Procedural sedation and analgesia (PSA) has long been a core skill of the emergency physician, over the last decade, developments in patient monitoring and the use of newer sedative and analgesic agents have served to improve both safety and efficacy [1]. Despite these advances and their consolidation into well-designed guidelines [2, 3], concern regarding the safety of emergency department (ED) PSA persists [4, 5]. Propofol in the ED is currently given as a repeated bolus (normally a few millilitres at a time until the desired effect is achieved)
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