Procedural Sedation Analgesia Research Articles

Comparison of supracondylar radial nerve block and procedural sedation analgesia in the reduction of radius fractures

Background and Aim: Distal radius fractures are the most frequent upper extremity fractures in the whole population. The incidence of distal radius fractures is 195.2/100,000, and the rate is increasing. It can occur with low-energy trauma in the elderly associated with osteoporosis. The purpose of this study is to compare the two different treatment groups (1. Sedation analgesia, 2. Supracondylar radial nerve block) in terms of reduction in Visual Analogue Scale (VAS) score, the length of hospital stay, complications, side effects, patient-physician satisfaction, and the ease of application. Materials and Methods: Patients diagnosed with distal radius fracture were enrolled prospectively, to whom the study’s exclusion criteria do not apply. The patients included in the study were randomly separated into two groups. Ketofol was administered to the sedation and analgesia group’s patients at a dose of 0.5 mg/kg (ketamine 0.5 mg/kg, propofol 0.5 mg/kg) intravenously, and supracondylar radial nerve block was performed on the other group’s patients under ultrasound guidance. Results: There were 20 patients (6 male, 14 female) in the sedation and analgesia group and 21 patients (11 male, 10 female) in the supracondylar radial nerve block group. There was no significant difference between the groups regarding patient-physician satisfaction and complications. The length of hospital stay was significantly shorter in the supracondylar radial nerve block group (49.25 ± 4.05) compared with the sedation and analgesia group (125 ± 5.85) (p < 0.01). The mean reduction VAS score in the block group was observed to be lower than the admission VAS score (p < 0.01). Conclusion: Consequently, ultrasound-guided supracondylar radial nerve block would be a valuable alternative to procedural sedation analgesia and could become routine clinical practice in treating distal radius fractures.

Procedural sedation analgesia in prehospital settings: The state of the art

The utilization of analgosedation procedures is progressively becoming more prevalent in conducting a diverse spectrum of procedures necessitated by the patient’s clinical condition. Such procedures may be undertaken by physicians, anaesthesia nurses, and paramedics alike. Due to the broad competencies of employees of the state emergency medical system, it is possible to carry out analgosedation in the prehospital setting. However, performing analgosedation in that situation presents considerable challenges owing to limited familiarity with the patient’s history, available equipment, and environmental conditions at the scene. Hence, prehospital healthcare providers must possess comprehensive knowledge of the procedural capabilities and technical skills associated with analgosedation to mitigate the risk of adverse events. Proficiently executed analgosedation, based on the conscious use of available equipment, medications and the procedure’s capabilities holds significant importance in achieving the desired procedural outcomes and positively impacting the patient’s clinical status. As no formal guidelines in analgosedation for prehospital providers have been developed the authors aimed to summarize current knowledge and skills required to minimize the risk for patients. The authors also aimed to highlight the necessity of responsible and thoughtful training to perform analgosedation in the prehospital setting to develop desirable correct habits and increase situational awareness.

Bilateral Elbow Dislocation Without Fracture After Minor Trauma in a Healthy Adult Man

The elbow is the second most frequently dislocated major joint in adults. Elbow dislocation is a common traumatic injury, occurring in approximately 20% of all joint dislocations. Falling onto an outstretched hand is the most prevalent cause of elbow dislocation. Simultaneous bilateral elbow dislocation is a rare presentation, and reports of similar injuries are very limited. A 21-year-old male patient was brought to the emergency department after landing on both hands with flexed elbows from a height of one meter while doing home decoration work. The posterolateral dislocations was detected in both elbows without a fracture on the plain radiographs. The patient's elbows were reduced under procedural sedation analgesia in the emergency department. The patient's splints were removed in the orthopedics outpatient clinic after a 2-week follow-up, and he had no complications. It should be noted that serious bilateral dislocations can occur even in minor traumas like this. Procedural sedation not only prevents the delay of the procedure and the occurrence of complications, especially during the treatment of such multiple dislocations, but also increases patient comfort.

Procedural sedation analgesia in the elderly patient.

Elderly patients are perceived as a high-risk group for procedural sedation. Procedural sedation analgesia (PSA) is generally safe in older adults. What is not acceptable is undertreating pain or inadequately sedating a stable patient. All the usual precautions should be taken. One should consider any comorbidities that could make the patient more at risk of adverse reactions or complications. Older patients may be at higher risk for oxygen desaturation, but they usually respond quickly to supplemental oxygen. Geriatric patients usually require lower doses of medications. They tend to be more sensitive to medications, with slower metabolism, less physiologic reserve to handle side effects, and a smaller volume of distribution. The use of drugs for sedation in elderly patients requires careful consideration of their age-related changes in physiology and pharmacokinetics. The choice of drug should be based on the patient's medical condition, comorbidities, and potential adverse effects. Moreover, the administration should be done by trained personnel with close monitoring of vital signs and level of consciousness to prevent complications such as respiratory depression.

Is intranasal dexmedetomidine superior to oral chloral hydrate for procedural sedation in children: A systematic review.

Background:This systematic review was undertaken to compare the benefits of intranasal dexmedetomidine (IND) versus oral chloral hydrate (OCH) in the pediatric age group undergoing procedural sedation analgesia (PSA). Randomized clinical trials (RCT) of the various studies done over the years were taken up and analyzed. Since IND has the additional advantages of a faster onset of action, greater success with a single bolus dose, and enhanced recovery, this systematic review was conducted to prove the superiority of IND over OCH in pediatric PSA.Objective:To compare the efficacy of IND versus OCH for PSA in pediatric patients.Search Strategy:We searched the electronic databases from August 2012 to September 2019 without language restrictions.Design and Selection Criteria:A review of 10 RCTs on the use of IND and OCH for PSA in the pediatric age group for a variety of diagnostic procedures was done and the superiority of IND as per the sedation time and adverse effects were analyzed.Results:Out of the RCTs considered, six trials were a direct comparison between OCH and IND which showed that IND had a faster onset of action, improved recovery characteristics with better return to baseline physical activity on the same day of the procedure. When compared to OCH, IND showed no evidence of second-dose requirement and no record of postoperative nausea and vomiting (PONV).Conclusion:This systematic review revealed that IND is superior to OCH for PSA in the pediatric age group and proved to be safe and effective with better recovery characteristics.

Four year evaluation of therapeutic hysteroscopy under procedural sedation in an outpatient clinic

ObjectiveDue to the evolution of hysteroscopic instruments, therapeutic hysteroscopic procedures are increasingly performed in an outpatient, office-based setting. The most important limiting factor of performing these hysteroscopic treatments is patient discomfort. Procedural Sedation Analgesia (PSA) decreases patient discomfort and anxiety. The main goal of this study is to determine safety, feasibility and patient satisfaction of therapeutic hysteroscopy performed under procedural sedation in an outpatient clinic. Our second objective was to compare 9 mm scopes with smaller diameter scopes. Study designAll consecutive patients suitable for procedural sedation and scheduled for a therapeutic hysteroscopy in the outpatient clinic were prospectively included from February 2014 to November 2018 in a teaching hospital in the Netherlands. A variety of therapeutic hysteroscopies procedures was performed including myomectomy, removal of retained products of conception and endometrial ablation. Therapeutic hysteroscopes with 3.8 mm, 5 mm and 9 mm diameter were used. In all selected women procedure time, admission time, pain scores, anaesthesiologic and procedural complications were assessed. All women received a questionnaire on patient satisfaction. ResultsIn total 455 patients underwent a therapeutic hysteroscopy. Median procedure time was 11 min (2–63 min) and median admission time was 130 min (30–480 min). Median pain score according to the visual analog scale (VAS) before, during and after procedure were respectively 0 (0–10), 0 (0–4) and 0 (0–9). Anaesthesiologic complication rate was 4.4 %, all minor. Procedural complications consisted of infection postoperatively (0.4 %), excessive blood loss during procedure (0.6 %) and perforation (0.4 %). Procedure was incomplete in 3.3 % of all procedures. Patient satisfaction was high, as 96 % of the women were satisfied. No differences were found in pain scores, VAS 0 versus 1 after the procedure, between 3.8 or 5 mm and 9 mm scopes. ConclusionIt is safe and feasible to perform a therapeutic hysteroscopy under procedural sedation in an outpatient setting, with low pain scores and a high degree of patient satisfaction, also when large diameter instruments are used.

“FROG-LEGGED TRAUMA PATIENT”. BILATERAL ANTERIOR HIP DISLOCATION.

Anterior hip dislocation is rare (10-15% occurrence) compared with posterior dislocation. Bilateral simultaneous anterior hip dislocation is even extremely rare. Most of the previously reported case were either a unilateral or combination of anterior and posterior dislocation. We present a case of bilateral anterior hip dislocation post motor vehicle accident. Patient brought in the Emergency Department in “frog-legged” posture, unable to straighten the lower limbs. Even the Pre-Hospital Care (PHC) team had a tough time to load the patient onto the ambulance stretcher. On examination, both lower limbs were held in abduction, external rotation and in flexion position. Neurovascular assessments were intact. Pelvic x-ray shows bilateral anterior hip dislocation, right iliac bone fracture and left greater trochanteric femur fracture. Closed manual reduction of both hip were performed under procedural sedation analgesia. CECT pelvic done later confirmed right iliac bone fracture extending to and comminuted fracture of the left greater trochanteric. Bilateral avascular necrosis of both femoral head was also noted. Traumatic hip dislocations are a true orthopedic emergency. Early reduction (within 6 hours) is required as soon as appropriate x-rays have been obtained to exclude associated injuries since avascular necrosis of the femoral head increases in direct proportion to delay in reduction. If this fails, closed reduction under general anesthesia is indicated.

Patient Satisfaction and Understanding of Moderate Sedation During Endoscopy.

Millions of endoscopic procedures are performed in the US every year and the use of procedural sedation analgesia (PSA) is increasing with more procedures being performed outside the operating theater and gaining popularity due to reduced costs. Patients having endoscopic procedures usually expect that they would be deeply sedated during the procedure despite verbal counseling during pre-procedure clinic visits and are often dissatisfied with procedural awareness and discomfort. In order to better educate patients, written supplementary reading material was provided to the patients, which stated a clear goal of comfort during the procedure rather than deep sedation. The results showed that the written supplementary material did not improve the patient’s understanding or remembrance of being counseled about moderate sedation. We emphasize that there is no substitute for a physician’s repetitive verbal counseling.

Analgosedation for diagnostic and interventional procedures: a countrywide survey of pediatric centers in Germany

BackgroundAs more and more diagnostic and interventional options are becoming available for use in pediatric patients, techniques of procedural sedation analgesia (PSA) are being administered in considerably growing numbers as well.AimsThe objective of this research effort was to conduct the first countrywide survey on the status quo of sedation analgesia as delivered to children and adolescents in Germany.MethodsWe dispatched letters to all pediatric hospital settings in Germany (n = 305), including a questionnaire that had been developed with existing guidelines taken into account. Its items were designed to elucidate the current practice of PSA throughout these pediatric centers regarding (a) organizational structures and (b) standards of medication and staffing.ResultsA total of 138 centers returned the questionnaire, hence the response rate was 45.2%. Numerous centers had implemented adequate structures and staffing standards. Deficits were nevertheless identified, most notably in terms of on-location equipment and staff provided to deliver sedations. Essential items of equipment were not provided in up to 26.8% of centers. Adequate staffing was not provided in up to 44.2% of centers, depending on the diagnostic or interventional procedures for which the PSA was delivered. The most widely used sedative agents were midazolam, ketamine/esketamine, and propofol.ConclusionsAdequate care structures for the management of procedural sedation analgesia have been implemented by many pediatric centers in Germany. On the downside, these findings also reveal deficits that will take efforts to be eliminated.

Procedural Sedation and Analgesia in Trauma Patients in an Out-of-Hospital Emergency Setting: A Prospective Multicenter Observational Study

Background: The quality of procedural analgesia and sedation among trauma patients has not been studied much in the prehospital setting. The main objective of this study was to characterize the quality of procedural analgesia sedation practices in prehospital settings in trauma patients. Methods: This was an open-label observational prospective multicenter study (January 01, 2012–December 31, 2013). We included all consecutive trauma victims undergoing a potentially painful procedure on the accident scene. The primary endpoint was the procedural pain intensity. Results: Data for 210 patients aged 11 to 98 years were analyzed. The most common lesions were limb fractures or dislocations. The most common procedures were limb realignment and splinting. Overall, 25 different drug combinations [with paracetamol [acetaminophen], non-steroidal anti-inflammatory drugs, nefopam, opioids, loco-regional anesthesia, Equimolar Mixture of Oxygen/Nitrous Oxide (EMONO), sedative drugs] were used by the emergency medical services (EMS). One hundred seventeen patients (55%) received either one or two sedative drugs (among ketamine, propofol, and midazolam), 171 patients (81%) received morphine that was combined with a sedative drug in 54% of cases. During the procedure, 95 patients, 45% [95% Confidence Interval (CI) 39–52] experienced intense to severe pain. Among patients who received sedative drugs, 27% (32/117) had intense to severe pain vs. 68% (63/93) in patients who did not, that is, 40% difference [95% CI 33.8–47.0]. Seventeen patients (8%) experienced 18 adverse events of which 6 were respiratory adverse events. A deep sedation occurred in 17 patients. No center had any specific protocols for procedural sedation analgesia. Conclusion: Procedural sedation-analgesia was inadequate in almost half of the trauma patients in the out-of-hospital setting. The reasons of these failures were probably multiple. The non-administration of a sedative drug despite an indication or non-adapted doses, in the context of a lack of specific protocols, was certainly one of them.

Ön Kol Kırıklarında USG Eşliğinde Aksiller Yaklaşımlı Brakial Pleksus Bloğu

Background: In Emergency Departments EDs , procedural sedation analgesia, hematoma block, intravenous regional anaesthesia and peripheral nerve blocks are usually used for pain control in forearm fractures. We aimed to review the results of Visual Analog Scale VAS scores during examination and reduction , post reduction neurovascular examinations and complications of forearm fractures which were applied US-guided axillary approach of brachial plexus block AABPB . Patients and Methods: We described fourteen patients, who presented to the ED with forearm fractures, and were reduced using US-guided AABPB performed by emergency physicians. The same technique was used for all fourteen nerve blocks. We reviewed the results of VAS scores during examination and reduction , post reduction neurovascular examinations and complications of forearm fractures who were applied AABPB. Results: Of the 14 patients admitted to study, the mean age was 59.92 ±12,81 36.00 – 82.00 . Mean VAS score of patients before procedures was 91.57 ± 3.99 85,00 – 98.00 mm. The US-guided AABPB was performed by emergency physicians and nerve block fracture was reduced. 20 minutes after reduction, mean VAS score of patients was 10.21 ± 5.36 0 – 19.00 mm. performed Table 1 . All patients were discharged after approximately eight hours’ observation period and post-reduction neurovascular examinations were normal. There were no complications during block and reduction. Conclusion: US-guided axillary approach of brachial plexus block is a technique that can be applied easily in the ED by emergency physicians for forearm fractures. In this technique, the procedural success rate is high, and it was noticed a high level of patient and physician satisfaction.

Comparison of Suprascapular Nerve Block and Procedural Sedation Analgesia with Intravenous Ketamine and Midazolam in Shoulder Dislocation Reduction

Comparison of Suprascapular Nerve Block and Procedural Sedation Analgesia with Intravenous Ketamine and Midazolam in Shoulder Dislocation Reduction

Modeling the costs and benefits of capnography monitoring during procedural sedation for gastrointestinal endoscopy.

Background and study aims: The addition of capnography to procedural sedation/analgesia (PSA) guidelines has been controversial due to limited evidence of clinical utility in moderate PSA and cost concerns. Patients and methods: A comprehensive model of PSA during gastrointestinal endoscopy was developed to capture adverse events (AEs), guideline interventions, outcomes, and costs. Randomized, controlled trials and large-scale studies were used to inform the model. The model compared outcomes using pulse oximetry alone with pulse oximetry plus capnography. Pulse oximetry was assumed at no cost, whereas capnography cost USD 4,000 per monitor. AE costs were obtained from literature review and Premier database analysis. The model population (n = 8,000) had mean characteristics of age 55.5 years, body mass index 26.2 kg/m2, and 45.3 % male. Results: The addition of capnography resulted in a 27.2 % and 18.0 % reduction in the proportion of patients experiencing an AE during deep and moderate PSA, respectively. Sensitivity analyses demonstrated significant reductions in apnea and desaturation with capnography. The median (95 % credible interval) number needed to treat to avoid any adverse event was 8 (2; 72) for deep and 6 (−59; 92) for moderate. Reduced AEs resulted in cost savings that accounted for the additional upfront purchase cost. Capnography was estimated to reduce the cost per procedure by USD 85 (deep) or USD 35 (moderate). Conclusions: Capnography is estimated to be cost-effective if not cost saving during PSA for gastrointestinal endoscopy. Savings were driven by improved patient safety, suggesting that capnography may have an important role in the safe provision of PSA.

A comparison of suprascapular nerve block and procedural sedation analgesia in shoulder dislocation reduction

ObjectivesDislocation of the shoulder joint is one of the most common dislocations. The reduction procedure is a painful procedure. In this study, 2 different treatment groups were compared for pain control during shoulder dislocation reduction. It was aimed to evaluate the differences between the groups in reduction, success, length of hospital stay, complications, side effects, patient-physician satisfaction, and ease of application. MethodsThe study was planned to be prospective and randomized. As procedural sedation analgesia (SA), titration of ketamine 1 to 2 mg/kg was administered intravenously to group 1. Suprascapular nerve block (SNB) was applied under ultrasound guidance (USG) to group 2. Conformity to normal distribution of variables was examined with the Kolmogorov-Smirnov test. The χ2 test and Fisher test were used to evaluate differences between the groups in categorical variables and the Mann-Whitney U test, and a value of P < .05 was accepted as statistically significant. ResultsThe study comprised a total of 41 patients; 20 in the group 1 and 21 in the group 2. No statistically significant difference was determined between the groups in terms of age (P = .916), sex (P = .972), reduction success (P = .540), and patient-physician satisfaction (P = .198). The time spent in the emergency department (ED) by patients in the SA group was signficantly longer compared with the SNB group. No side effects were observed in the SNB group. ConclusionsSuprascapular nerve block, which can be easily applied under USG in the ED, can be evaluated as a good alternative to SA in the reduction of shoulder dislocations.

Is it safe to use propofol in the emergency department? A randomized controlled trial to compare propofol and midazolam

BackgroundThis study examined the safety and effectiveness of the procedural sedation analgesia (PSA) technique carried out in the emergency department (ED) of a university hospital over a period of 1 year. The research was done to compare the effectiveness and efficacy of moderate sedation of fentanyl combined with either midazolam or propofol for any brief, intense procedure in the ED setting.AimsThe objectives were to observe the occurrence of adverse events in subjects undergoing PSA for intense and painful procedures in the emergency department and to implement the use of capnography as a method of monitoring the patients when they were under PSA.MethodsForty patients were selected for this study. They were randomly divided into two equal groups using the computer-generated random permuted blocks of four patients. Twenty patients were grouped together as group A and the remaining 20 patients as group B. Drugs used were single blinded to prevent any bias. Drug A was propofol and fentanyl, while drug B was midazolam and fentanyl. The procedures involved included orthopedic manipulation such as reduction of fractures, reduction of dislocated joints, abscess drainage, wound debridement, laceration wound repair and cardioversion. All of the subjects were monitored for their vital signs and end tidal carbon dioxide level every 10 min till the PSA was completed. The duration of stay in the ED was documented when the subjects had completed the procedure and were released from the department.ResultOf the study population, 75.6% were males. The mean age was 37.8 years (95% CI 33.2, 39.8). None of the patients developed any major complications while under PSA. The vital signs pre-, intra- and post-procedure were not significantly different in either the propofol or mizadolam groups (p value >0.05).ConclusionThis study had proven that there was no difference in adverse event occurrence between the studied drugs during PSA. Propofol can be recommended for use in PSA if the operator is well trained and familiar with the drug.

Procedural sedation analgesia

The number of noninvasive and minimally invasive procedures performed outside of the operating room has grown exponentially over the last several decades.Sedation, analgesia, or both may be needed for many of these interventional or diagnostic procedures. Individualized care is important when determining if a patient requires procedural sedation analgesia (PSA). The patient might need an anti-anxiety drug, pain medicine, immobilization, simple reassurance, or a combination of these interventions. The goals of PSA in four different multidisciplinary practices namely; emergency, dentistry, radiology and gastrointestinal endoscopy are discussed in this review article. Some procedures are painful, others painless. Therefore, goals of PSA vary widely. Sedation management can range from minimal sedation, to the extent of minimal anesthesia. Procedural sedation in emergency department (ED) usually requires combinations of multiple agents to reach desired effects of analgesia plus anxiolysis. However, in dental practice, moderate sedation analgesia (known to the dentists as conscious sedation) is usually what is required. It is usually most effective with the combined use of local anesthesia. The mainstay of success for painless imaging is absolute immobility. Immobility can be achieved by deep sedation or minimal anesthesia. On the other hand, moderate sedation, deep sedation, minimal anesthesia and conventional general anesthesia can be all utilized for management of gastrointestinal endoscopy.

Effects of Initial Pain Treatment on Sedation Recovery Time in Pediatric Emergency Care

The purpose of this study is to compare the sedation recovery times of children receiving ketamine/midazolam (K/M) versus K/M and initial pain treatment (morphine or meperidine) in pediatric emergency care. Study method was a retrospective cross-sectional study of children receiving K/M for procedural sedation analgesia in an urban children's hospital pediatric emergency department (ED). A uniform data collection form was completed for each child. During an 18-month period, 116 children received K/M for procedural sedation analgesia in the ED. For this study, 80 children met inclusion criteria: 33 patients received K/M only; 32 received K/M and morphine, and 15 received K/M and meperidine. In comparing the K/M only group with the K/M morphine and K/M meperidine groups, the mean ketamine and midazolam doses (mg/kg) were not significantly different. In comparing the recovery times (minutes) for the K/M only group (29.7; SD, 15.7) with the K/M morphine (41.1; SD, 22.4) and K/M meperidine (50.1; SD, 24.9) groups, there was a significant difference for both comparisons (95% confidence interval for difference between 2 means, -20.9 to -1.76 and -32.2 to -8.4, respectively). Sedation (K/M) recovery time is significantly greater for children receiving initial pain treatment (morphine or meperidine). Children receiving meperidine had the longest recovery time. Considering this prolonged recovery time and the unique adverse effects of meperidine compared with morphine, we recommend meperidine not be used for initial ED pain treatment of children.

Scapular manipulation technique for reduction of traumatic anterior shoulder dislocations: experiences of an academic emergency department

Background: Shoulder dislocations account for almost 50% of all joint dislocations, which are most commonly anterior (90–98%) and occur due to trauma. This prospective study was conducted to report our...