Procedural Sedation In Emergency Department Research Articles

Procedural Sedation in Emergency Department: A Narrative Review

Procedural sedation and analgesia (PSA) in the emergency department (ED) presents a crucial aspect of emergency medicine, enabling the execution of painful or distressing procedures with minimal patient discomfort. This narrative review delineates the pharmacological framework, methodologies, and clinical considerations integral to optimizing PSA, with a particular focus on pediatric and geriatric populations. Through a comprehensive review and analysis of current practices, this work evaluates the pharmacokinetics and pharmacodynamics of widely utilized sedatives and analgesics, including propofol, ketamine, dexmedetomidine, fentanyl, midazolam, etomidate, nitrous oxide, and remimazolam. Special attention is dedicated to the selection criteria based on patient-specific risk factors, procedural requirements, and the management of potential adverse effects. The manuscript also explores innovative sedation techniques and the integration of new pharmacological agents, emphasizing evidence-based approaches to enhance patient safety and outcome. The results underscore the significance of tailored sedation strategies, especially for vulnerable groups such as pediatric and geriatric patients, highlighting the need for meticulous pre-procedural assessment and monitoring to mitigate risks. The conclusions drawn advocate for a nuanced application of PSA, guided by current evidence and clinical guidelines, to improve the quality of care in emergency settings. This research reinforces the imperative for ongoing education, skill development, and the adaptation of new evidence into clinical practice to advance procedural sedation and analgesia in the ED.

Use of Ketamine, Propofol and Their Combination (KETOFOL) For Procedural Sedation in Emergency Department: A Review

For Procedural Sedation, sedative and Analgesic agents are frequently used in Emergency Department but titration of anesthetic doses should be performed with care, and patients should be continuously monitored. The use of Ketamine, Propofol and their combination (Ketofol) is in common practice, but there is currently no intravenous anesthetic agent that is ideal. Therefore, this review was conducted to analyze the efficacy as well as the potential side effects of these anesthetic agents during procedural sedation. Method: For this purpose, Medline, EMBASE, CCRCT and CINAHL were searched and systematically analyzed and the meta-analysis included all English-language randomized control trials (RCTs) comparing K-P vs propofol for procedural sedation in ED. The study included the data of ED patients who received procedural sedation for non-elective unpleasant procedures. Results: As a result of the removal of duplicate citations and studies that did not fulfill eligibility requirements, a total of 06 RCTs involving 932 patients (412 in the propofol group and 520 in the K-P group). Very high levels of inter-rater reliability (j = 0.88; 95% CI = 0.68 to 1.0) were found in the final selection of included trials, with 95.2% agreement. Conclusion: Data revealed that the combination of Ketamine with propofol was the most effective anesthetic combination in the larger randomized, prospective studies carried out in the ED that had sufficient power to use the maintenance of vital signs and the success of the procedure as endpoints are still required

366 Cocaine Use Is Associated With Adverse Events in Emergency Department Procedural Sedation

In the emergency department (ED), patients commonly require procedural sedation (PS). This is performed in order to minimize the pain and anxiety associated with various diagnostic and therapeutic procedures. There is currently no large scale study which investigates how cocaine affects the incidence of adverse events (AE) in ED PS.

The effect of emergency department procedural sedation on cardiac output: post hoc analysis of a prospective study.

The effect of emergency department procedural sedation on cardiac output: post hoc analysis of a prospective study.

The utilization of procedural sedation and analgesia at the University Teaching Hospital of Kigali, Rwanda

Introduction: In the Emergency Department (ED), safe and effective Procedural Sedation and Analgesia (PSA) is essential. The professional performing procedural sedation has to be prepared to handle any potential adverse effects. Medications are used according to their availability and based on the physician’s experience and preference. Despite the common occurrence of procedural sedation in the ED, it has not previously been studied in Rwanda. The study aimed to describe procedural sedation and analgesia utilization and common adverse events at Rwanda's University Teaching Hospital of Kigali (UTH-K) ED.Methods: This study is a prospective observational study of procedural sedations done at UTH-KED. The effectiveness of sedation was evaluated using the Richmond Agitation Sedation Score (RASS) during sedation. The pain scale was assessed before and after the procedure. Categorical data were analyzed for significant differences using Chi-squared (X) tests and continuous data with Mann-Whitney (MW) tests.Results: Two hundred fifty-one patients were recruited. Seventy-two percent (72%) of patients were male with a median age of 32 years (IQR 23to 40). The most commonly used analgesics included morphine (78%) and tramadol (17%), with ketamine least used (1%). A common adverse event was hypoxia (36%), followed by hallucination (8%). No adverse events were observed in 47% of procedures. Conclusion: Our study findings suggest that although sedation in our low-resource setting did not result in serious adverse outcomes for patients, there was a much higher incidence of minor adverse events (especially hypoxia) than in higher-resource settings.

Single-Shot Sub-Dissociative Dose Ketofol versus Ketamine Alone for Emergency Department Procedural Sedation and Analgesia in Adult

When compared with Ketamine alone for PSA in ED settings, the Ketofol with rapid onset of action, faster recovery time, cardio respiratory stability, less adverse events, and high patient satisfaction level make it a better option.

Fifteen Years' Experience With Safe and Effective Procedural Sedation in Infants and Children in a General Emergency Department.

To evaluate procedural sedation (PS) in infants/children, performed by emergency physicians in a general (nonpediatric) emergency department (ED). Procedural sedation prospectively recorded on a standardized form over 15 years. Demographics, sedatives, and analgesia associations with adverse events were explored with logistic regressions. Of 3274 consecutive PS, 1177 were pediatric: 2 months to 21 years, mean age (±SD) 8.7 ± 5.2 years, 63% boys, 717 White, 435 Black, 25 other. Eight hundred and seventy were American Society of Anesthesiology (ASA) 1, 256 ASA 2, 39 ASA 3, 11 ASA 4, 1 ASA 5. Procedural sedation indications are as follows: fracture reduction (n = 649), dislocation reduction (n = 114), suturing/wound care (n = 244), lumbar puncture (n = 49), incision and drainage (n = 37), foreign body removal (n = 28), other (n = 56). Sedatives were ketamine (n = 762), propofol ( = 354), benzodiazepines (n = 157), etomidate (n = 39), barbiturates (n = 39). There were 47.4% that received an intravenous opioid. Success rate was 100%. Side effects included nausea/vomiting, itching/rash, emergence reaction, myoclonus, paradoxical reaction, cough, hiccups. Complications were oxygen desaturation less than 90%, bradypnea respiratory rate less than 8, apnea, tachypnea, hypotension, hypertension, bradycardia, tachycardia. Normal range of vital signs was age-dependent. Seventy-four PS (6.3%) resulted in a side effect and 8 PS (3.2%) a complication. No one died, required hospital admission, intubation, or any invasive procedure. Adverse events in infants/children undergoing PS in a general ED are low and comparable to a pediatric ED at a children's hospital. Pediatric PS can be done safely and effectively in a general ED by nonpediatric EM physicians for a wide array of procedures.

Effect of Ketamine on Cardiovascular Function During Procedural Sedation of Adults.

Introduction: Ketamine is commonly used in emergency department procedural sedation. Mild to moderate transient increases in blood pressure, heart rate, and cardiac output are common due to ketamine causing an increase in sympathetic activity. There is a concern that these physiological changes could result in an increased myocardial oxygen demand that may exacerbate underlying cardiac disease.Methods: Convenience sample of patients older than 50 years receiving ketamine for procedural sedation in the emergency department was used (n = 31). Patients were selected to receive ketamine based on provider discretion. Primary outcome was incidence of new myocardial ischemia apparent on an electrocardiogram (ECG). ECGs were obtained prior to sedation and during the sedation approximately one minute after administration of ketamine. ECGs were reviewed by a board-certified emergency medicine physician and a board-certified cardiologist.Results: New onset ischemia was found in 9.7% (3/31) of ECGs. Of these, one was in a patient who had previously received ketamine without evidence of ischemia on the repeat ECG. There were no statistically significant differences between the groups. Evidence of ischemia on ECG did not impact patient disposition.Conclusions: Ketamine is a useful medication in procedural sedation; however, careful attention should be made in patient selection when ketamine is the desired agent. Consideration might be made in using the lowest possible dose of ketamine to obtain adequate sedation in order to hopefully lessen the occurrence of ECG changes suggestive of myocardial ischemia. Based on this small sample, single-site study, no evidence of statistically or clinically significant ischemia was seen with the use of ketamine for procedural sedation. Ketamine remains a safe medication option in adults undergoing procedural sedation.

Impact of young age on outcomes of emergency department procedural sedation.

Relatively little is known about outcomes of procedural sedation in very young children. Our objective was to examine the association between procedural sedation in young children (≤ 2years) and the incidence of sedation-related adverse events. This is a secondary analysis of a prospective cohort study of children 0 to 18years undergoing parenteral procedural sedation in six Canadian pediatric emergency departments (ED). The primary risk factor was age≤2years. Secondary risk factors were sex, procedure type, pre-procedure and sedation medications. The outcomes examined were: serious adverse events (SAE), significant interventions, oxygen desaturation and vomiting. Of the 6295 patients included, 946 (15%) were ≤2years. Children 13-24months comprised 90% of the young age group. Children≤2years were sedated most commonly for laceration repair (n=450; 47.6%), while orthopedic reduction was most common in children>2 (n=3983; 74.5%). Ketamine was the most common medication in both groups, but was used more frequently in children≤2years (80.9% vs 58.9%; p<0.001). There was no difference in the odds of SAE (OR 0.83, 95% Confidence Interval (CI) 0.4 to 1.9), significant intervention (OR 0.82, 95% CI 0.4 to 1.7) or oxygen desaturation (OR 0.95, 95% CI 0.7 to 1.3) between age groups, however children≤2years vomited less frequently (OR 0.24, 95% CI 0.1 to 0.6). Young age, specifically between 13 and 24months, was not associated with a significant difference in the incidence of adverse events.

Nonconcentric and Irregular Dislocations of Total Hip Arthroplasties: Radiographic Analysis and Review of the Literature.

Total hip arthroplasty (THA) is one of the most successful operations in all of medicine in improving patient pain and restoring function. However, complications do arise after primary and revision THA. Dislocation of a THA, also known as instability, occurs in 1-2% of primary THAs and up to 30% of revision THAs. Most dislocations in the United States are initially managed with closed reduction under procedural sedation in emergency departments (EDs) by on-call orthopedists or emergency medicine specialists. In this review the characteristics of the articulations that may require closed reduction in the ED are described, as well as their radiographic findings prior to reduction. Finally, we present subtle radiographic findings associated with failed closed reductions. Due to the different types of implants that have been introduced, closed reduction can be challenging in certain cases. Iatrogenic intraprosthetic dislocations are becoming more common with the increased use of dual-mobility liners. There are also dislocations after staged revision THA cases with the use of spacers. In spacers with semi-constrained articulation, there is the possibility of partial reduction of the spacer. Dislocation is one of the most common mechanical complications after primary and revision THA. In the majority of the cases, acute closed reduction can be achieved successfully in the ED setting. However, there are specific dislocation types that present unique challenges to acute reduction.

Comparison of the effects of dexmedetomidine and propofol in reducing recovery agitation in pediatric patients after ketamine procedural sedation in emergency department.

Background:Ketamine has been a safe and effective sedative agent commonly used for painful pediatric procedures in the emergency department (ED). This study aimed to compare the effect of dexmedetomidine (Dex) and propofol when used as co-administration with ketamine on recovery agitation in children who underwent procedural sedation.Materials and Methods:In this prospective, randomized, and double-blind clinical trial, 93 children aged between 3 and 17 years with American Society of Anesthesiologists Class I and II undergoing short procedures in the ED were enrolled and assigned into three equal groups to receive either ketadex (Dex 0.7 μg/kg and ketamine 1 mg/kg), ketofol (propofol 0.5 mg/kg and ketamine 0.5 mg/kg), or ketamine alone (ketamine1 mg/kg) intravenously. Incidence and severity of recovery agitation were evaluated using the Richmond Agitation-Sedation Scale and compared between the groups.Results:There was no statistically significant difference between the three groups with respect to age, gender, and weight (P > 0.05). The incidence of recovery agitation was 3.2% in the ketadex group, 22.6% in the ketofol group, and 22.6% in the ketamine group (P = 0.002, children undergoing short procedures were recruited). There was a less unpleasant recovery reaction (hallucination, crying, and nightmares) in the ketadex group compared with the ketofol and ketamine groups (P < 0.05). There was no difference in the incidence of oxygen desaturation between the groups (P = 0.30).Conclusion:The co-administering of Dex to ketamine could significantly reduce the incidence and severity of recovery agitation in children sedated in the ED.

Gastric point-of-care ultrasound evaluation in pediatric emergency department procedural sedation patients; is the stomach empty at the point of scheduled revisit?

Objectives: This study aimed to use gastric point of care ultrasound (POCUS) to estimate the prevalence of an “empty stomach” among patients undergoing procedural sedation and analgesia (PSA) in the emergency department (ED) after observing the requisite fasting time at home. Methods: A prospective observational study was conducted with children with facial lacerations who made a scheduled revisit to the ED after completion of the recommended fasting time. Their stomach contents were assessed with a sagittal view of the gastric antrum by POCUS in the right lateral decubitus position. The characteristics of gastric contents were described as empty, solid, and liquid with an estimated gastric volume. “Empty stomach” was defined as a collapsed gastric antrum or calculated a gastric fluid volume of less than or equal to 1.25 mL/kg on POCUS. Results: Gastric POCUS was performed in 125 patients, and the final analysis included 122 patients. For 95 patients who had followed the recommended fasting time, the median fasting time was 7 hours for solids and 6 hours for liquids, and 78 (82%) patients had an empty stomach. Conversely, seven of 27 patients (26%) who did not have an adequate fasting time had an empty stomach. The optimal cut-off value of fasting time to predict an empty stomach was 6.5 hours based on a receiver operating characteristic (ROC) analysis (sensitivity = 0.767, specificity = 0.811). Conclusions: Most scheduled revisiting children had an “empty stomach” at the time of sedation after the recommended fasting. However, providers should be aware that one in five children still had stomach residue, although they had more than 6 hours of fasting.

Regulatory Challenges to Emergency Medicine Procedural Sedation

As currently written, national regulatory guidance on procedural sedation has elements that are contradictory, confusing, and out of date. As a result, hospital procedural sedation policies are often widely inconsistent between institutions despite similar settings and resources, putting emergency department (ED) patients at risk by denying them uniform access to safe, effective, and appropriate procedural sedation care. Many hospitals have chosen to take overly conservative stances with respect to regulatory compliance to minimize their perceived risk. Herein, we review and critique standards and policies from the Centers for Medicare & Medicaid Services, The Joint Commission, state nursing boards, the Food and Drug Administration, and others with respect to their effect on ED procedural sedation. Where appropriate, we recommend modifications of and enhancements to their guidance that would improve the access of ED patients to modern, safe, and effective procedural sedation care.

84 Impact of young age on outcomes of emergency department procedural sedation

Abstract Background Procedural sedation in the emergency department (ED) for children undergoing painful procedures is common practice, however little is known about sedation in very young children. Objectives We examined the effect of young age on emergency department sedation outcomes. Design/Methods This is a secondary analysis of an observational cohort study of children 0-18 years undergoing procedural sedation in six pediatric EDs across Canada. We compared presedation state, indication for sedation, medications, sedation efficacy and four main post-sedation outcomes (serious adverse events (SAE), significant interventions, oxygen desaturation and vomiting) between patients who ≤ 2 years with those &amp;gt; 2 years. Pre-sedation state, medications, indication for sedation and time intervals were summarized using frequency and percentage and compared with chi2 test. Logistic regression was used to examine associations between age group and outcomes. Results 6295 patients were included: 5349 (85%) were &amp;gt; 2 years and 946 (15%) were ≤ 2 years. Children ≤2 years were sedated most commonly for laceration repair (n=450; 47.6%), orthopedic reduction (165; 17.4%) and abscess incision and drainage (136; 14.4%). Children &amp;gt;2years were sedated most commonly for orthopedic reductions (3983; 74.5%). Ketamine was the most common medication in both groups, but was used most frequently in children ≤ 2 years (80.9% vs 58.9%; p&amp;lt;0.001). There was no difference in the incidence of SAE, significant interventions or oxygen desaturation between age groups, however, children ≤ 2 years were less likely to vomit (Table 1). Young children had decreased odds of a successful sedation (OR 0.48; 95%CI: 0.37 to 0.63). On average, patients ≤ 2 years were sedated for 7 minutes less (74.1 vs 81.0 p&amp;lt;0.001) and discharged 10 minutes sooner (90.1 vs 100.8 p&amp;lt;0.001). Conclusion Children ≤ 2 years most commonly received ED sedation for laceration repair using ketamine. Young age was not associated with a significant difference in SAEs, significant intervention or desaturation but was associated with decreased odds of vomiting and of successful sedation.

Point-of-Care Ultrasound to Assess Gastric Content in Pediatric Emergency Department Procedural Sedation Patients.

There is debate regarding the timing of procedural sedation and analgesia (PSA) in relation to fasting status. Point-of-care ultrasound (POCUS) provides the ability to measure gastric content and is being used as a surrogate for aspiration risk in anesthesia. We sought to evaluate the gastric content of pediatric emergency department (PED) patients undergoing PSA using POCUS. We performed a prospective observational study using a convenience sample of pediatric patients undergoing PSA between July 1, 2018, and June 30, 2019. Following a brief history, gastric content was measured using POCUS in both supine and right lateral decubitus positions at 2-hour intervals until the time of PSA. Qualitative content and calculated volume were classified based on the Perlas Model of anesthesia "Risk" assessment. Ninety-three patients were enrolled with 61.3% male and mean age of 6.5 years. Gastric content was determined in 92 patients. There were 79.3% that had "high risk" content at the time of PSA, with a median fasting time of 6.25 hours and no serious adverse events. Fasting duration had a weak to moderate ability to predict "risk" category (area under the curve = 0.73), with no patient (n = 17) who underwent multiple evaluations awaiting PSA progressing from "high" to "low risk." The majority of PED patients undergoing PSA at our institution had "high risk" gastric content with no clinically significant change occurring during serial evaluations. This calls into question the utility of delaying PSA based upon fasting status and lends support to a more comprehensive risk-benefit approach when planning pediatric PSA.

Impact of Timing of Preprocedural Opioids on Adverse Events in Procedural Sedation.

The risk of respiratory depression is increased when opioids are added to sedative agents. In our recent multicenter emergency department (ED) procedural sedation cohort, we reported a strong association between preprocedural opioids and sedation-related adverse events. We sought to examine the association between timing of opioids and the incidence of adverse sedation outcomes. We conducted a secondary analysis of a prospective cohort of children aged 0 to 18years who received sedation for a painful procedure in six Canadian pediatric EDs from July 2010 to February 2015. The primary risk factor was timing of opioid administration, adjusted for age, opioid type, preprocedural and sedation medications, and procedure type. Outcomes were 1) oxygen desaturation, 2) vomiting, and 3) positive pressure ventilation (PPV). Of the 6,295 children in the original cohort, 1,806 (29%) received a preprocedural opioid. Patients receiving preprocedural opioids had a higher incidence of oxygen desaturation (risk difference= 4.3%, 95% confidence interval [CI]= 2.9% to 5.8%), vomiting (risk difference2.0%, 95% CI= 0.7% to 3.3%), and PPV (risk difference= 1.5%, 95% CI= 0.7% to 2.3%). Multivariable regression with timing of opioids modeled as a restricted cubic spline revealed the risk for each outcome was highest when opioids were administered in the 30minutes prior to sedation. Timing of opioid administration was statistically significantly associated with oxygen desaturation and vomiting (p<0.0001) but not with PPV (p=0.113). Timing of opioids was significantly associated with the risk of oxygen desaturation and vomiting. Being aware of this increased risk will help clinicians prepare for sedation and the potential need for patient rescue.

The Equivalence of Video Self-review Versus Debriefing After Simulation: Can Faculty Resources Be Reallocated?

Traditional simulation debriefing is both time- and resource-intensive. Shifting the degree of primary learning responsibility from the faculty to the learner through self-guided learning has received greater attention as a means of reducing this resource intensity. The aim of the study was to determine if video-assisted self-debriefing, as a form of self-guided learning, would have equivalent learning outcomes compared to standard debriefing. This randomized cohort study consisting of 49 PGY-1 to -3 emergency medicine residents compared performance after video self-assessment utilizing an observer checklist versus standard debriefing for simulated emergency department procedural sedation (EDPS). The primary outcome measure was performance on the second EDPS scenario. Independent-samples t-test found that both control (standard debrief) and intervention (video self-assessment) groups demonstrated significantly increased scores on Scenario 2 (standard-t(40)=2.20, p<0.05; video-t(45)=3.88, p<0.05). There was a large and significant positive correlation between faculty and resident self-evaluation (r=0.70, p<0.05). There was no significant difference between faculty and residents self-assessment mean scores (t(24)=1.90, p=0.07). Residents receiving feedback on their performance via video-assisted self-debriefing improved their performance in simulated EDPS to the same degree as with standard faculty debriefing. Video-assisted self-debriefing is a promising avenue for leveraging the benefits of simulation-based training with reduced resource requirements.

P116: Impact of young age on outcomes of emergency department procedural sedation

Introduction: Procedural sedation in the emergency department (ED) for children undergoing painful procedures is common practice, however little is known about sedation in very young children. We examined the effect of young age on sedation outcomes. Methods: This is a secondary analysis of an observational cohort study of children 0-18 years undergoing procedural sedation in six pediatric EDs across Canada. We compared presedation state, indication for sedation, medications, sedation efficacy and four main post-sedation outcomes (serious adverse events (SAE), significant interventions, oxygen desaturation and vomiting) between patients who ≤2 years with those &amp;gt;2 years. Pre-sedation state, medications, indication for sedation and time intervals were summarized using frequency and percentage and compared with chi2 test. Logistic regression was used to examine associations between age group and outcomes. Results: 6295 patients were included; 5349 (85%) were &amp;gt;2 years and 946 (15%) were ≤2 years. Children ≤2 years were sedated most commonly for laceration repair (n = 450; 47.6%), orthopedic reduction (165; 17.4%) and abscess incision and drainage (136; 14.4%). Children &amp;gt;2years were sedated most commonly for orthopedic reductions (3983; 74.5%). Ketamine was the most common medication in both groups, but was used most frequently in children ≤2 years (80.9% vs 58.9%; p &amp;lt; 0.001). There was no difference in the incidence of SAE, significant interventions or oxygen desaturation between age groups, however children ≤2 years were less likely to vomit (Table 1). Young children had decreased odds of a successful sedation (OR 0.48; 95%CI: 0.37 to 0.63). On average, patients ≤2 years were sedated for 7 minutes less (74.1 vs 81.0 p &amp;lt; 0.001) and discharged 10 minutes sooner (90.1 vs 100.8 p &amp;lt; 0.001). Table 1 ≤2 years (n = 946) &amp;gt;2 years (n = 5349) OR (95%CI)* p-value n(%) n(%) Serious Adverse Event 8 (0.85) 59 (1.0) 0.76 (0.43-1.7) 0.477 Significant intervention 10 (1.0) 76 (1.4) 0.74 (0.34-1.4) 0.374 Oxygen Desaturation 50 (5.3) 303 (5.6) 0.93 (0.67-1.3) 0.640 Vomiting 14 (1.5) 314 (5.9) 0.24 0.13-0.41) &amp;lt;0.001 *Reference category: ≤2 years. Conclusion: Children ≤2 years most commonly received ED sedation for laceration repair using ketamine. Young age was not associated with a significant difference in SAEs, significant intervention or desaturation but was associated with decreased odds of vomiting and of successful sedation.

Propofol for Emergency Department Procedural Sedation: Updated Guidance

Sponsoring Organizations: Five experts in emergency department (ED) sedation, including authors of a 2007 American College of Emergency Physicians

Clinical Practice Guideline for Emergency Department Procedural Sedation With Propofol: 2018 Update

We update an evidence-based clinical practice guideline for the administration of propofol for emergency department procedural sedation. Both the unique considerations of using this drug in the pediatric population and the substantial new research warrant revision of the 2007 advisory. We discuss the indications, contraindications, personnel requirements, monitoring, dosing, coadministered medications, and adverse events for propofol sedation.