Propofol For Procedural Sedation Research Articles

He outcome of Ketamine and Propofol for Procedural Sedation and Analgesia (PSA) in Pediatric Patients in the Emergency Department: A Cross-Sectional Study

bjectives: We aim to evaluate the outcomes of Ketamine and Propofol for PSA in pediatric Pakistani Emergency Department (ED) patients. Our primary objective is to observe sedation duration and recovery time. Secondary objective is to assess the need for repeat doses and potential complications associated with the use of these drugs. Study Design & Setting: Descriptive cross-sectional study. Urban tertiary care hospital: Aga Khan University Hospital (AKUH) ED, Pakistan. Methodology: 179 eligible patients requiring painful procedures in the emergency, under 16 years, selected through nonprobability consecutive sampling, after consent from caregiver/children, were included. PSA was performed by certified PALS and PSA personnel, with single IV Ketamine dose (0.5 mg/kg) and Propofol (1 mg/kg, followed by 0.5-1 mg/kg as needed). 15 Oxygen saturation and vital signs were continuously monitored during and after the procedure until full consciousness was regained and patients were observed for potential complications. RESULTS: 179 patients underwent PSA with Ketamine and Propofol combination; (57.0%) male and (43.0%) female, with a mean age of 3.91 years (± 2.80). Majority of patients were 1-5 years old (80.4%), 6-10 years (15.6%), and 11- 16 years (3.9%). Of these, (82.1%) required laceration repair. Some reversible complications were observed, including tachypnea in (28.5%) of cases, hypotension (22.3%), tachycardia (21.8%), bradycardia (2.2%) and hypoxia in (1.1%). CONCLUSION: In our study, PSA using Ketamine and Propofol combination in the ED, by non- anesthesiologists, was found to be safe and linked to a low rate of reversible complications.

Low-dose ketamine or opioids combined with propofol for procedural sedation in the emergency department: a systematic review.

Procedural sedation is routinely performed for procedures in the emergency department (ED). Propofol is a commonly used sedative, frequently combined with an opioid or low-dose ketamine as an analgesic. However, there is still controversy on the optimal combination of agents in current guidelines. The objective of this systematic review is to identify and present studies comparing low-dose ketamine to opioids when combined with propofol for procedural sedation in the ED and to describe the dosing regimen, observed efficacy, and side effects. For this systematic review, following the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines, EMBASE and PubMed databases were searched. Studies comparing propofol with opioids versus propofol with low-dose (es)ketamine in patients undergoing procedural sedation for procedures in the ED were included. Analyses were descriptive because of the high heterogeneity among included studies. The outcomes were dosing regimen, efficacy of analgesia, efficacy of sedation depth, efficacy of recovery and (adverse) events. We included four out of 2309 studies found in the literature search. Overall, the studies had a low risk of bias, but the Grading of Recommendations Assessment, Development, and Evaluation evidence profile was downgraded due to the imprecision and inconsistency of the studies. All studies compared low-dose ketamine with fentanyl. Dosing ranged from 0.3 to 1.0 mg/kg (ketamine), 1.0-1.5 μg/kg (fentanyl) and 0.4-1.0 mg/kg (propofol). The efficacy of analgesia was measured by two studies, one favoring the fentanyl group, and one favoring the ketamine group. The efficacy of sedation depth was measured by one study, with the fentanyl group having a deeper sedation score. Two studies showed shorter recovery time with low-dose ketamine. One study showed a higher incidence of cardio-respiratory clinical events and interventions in the fentanyl group. Two studies showed significant differences of overall sedation events in the fentanyl group. One study did not find any significant differences of the incidence of sedation events. This systematic review did not provide sufficient evidence that the combination of low-dose ketamine and propofol is associated with a shorter recovery time and fewer sedation events compared to the combination of opioids and propofol.

Economic benefits of remimazolam compared to midazolam and propofol for procedural sedation in colonoscopies and bronchoscopies

Background Sedation is common practice in endoscopic procedures to suppress a patient’s level of consciousness while maintaining the cardio-respiratory function. Midazolam and propofol are the sedatives most frequently used for procedural sedation at hospitals in Scandinavia. Remimazolam is a new ultra-short-acting benzodiazepine sedative and the present analysis aimed at estimating the economic benefits of introducing remimazolam for procedural sedation in colonoscopies and bronchoscopies in hospitals in Scandinavia. Method We developed a cost model applying a micro-costing approach that comprised the cost components that are affected by differences in the efficacy of remimazolam, midazolam, and propofol, and the model estimated the cost per successful colonoscopy and bronchoscopy when using remimazolam, midazolam or propofol as sedation. A micro-costing approach was applied, and the model consisted of six stages representing the journey for patients undergoing endoscopies and was informed primarily by data from clinical studies on remimazolam. Results We found a total cost of DKK 1200 per successful colonoscopy procedure when using remimazolam, a total cost of DKK 1320 when using midazolam, and a total cost of DKK 1255 when using propofol. Hence, the incremental saving per successful colonoscopy procedure of using remimazolam was estimated to be DKK 120 compared to midazolam and DKK 55 compared to propofol. The total cost per successful bronchoscopy procedure when using remimazolam was DKK 1353 and DKK 1724 for midazolam, resulting in an incremental saving per bronchoscopy of DKK 372 when using remimazolam. Performed sensitivity analyses identified the time in recovery as the largest contributor to uncertainty in the analyses of remimazolam compared to midazolam in colonoscopies and bronchoscopies. In the comparison of remimazolam and propofol in colonoscopies, procedure time was the largest contributor to uncertainty. Conclusion We found that procedural sedation with remimazolam was associated with economically meaningful savings compared to procedural sedation with midazolam and propofol in colonoscopies and to midazolam in bronchoscopies.

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

The Influence of Age on Propofol Dosing Requirements During Procedural Sedation in the Emergency Department.

Propofol is a frequently used agent for procedural sedation in the emergency department (ED). Some have suggested that propofol dosing in this setting should be adjusted in elderly patients; however, limited data exist supporting this recommendation. Additional factors that may contribute to altered propofol dose requirements in this setting have not been thoroughly explored. The objective of this analysis was to ascertain the effect age may have on the propofol dose required during procedural sedation in the ED. This retrospective study was conducted at a Level 1 academic medical center ED and included patients 18 years or older who received propofol for procedural sedation from 2015 to 2017. Those patients who were 18-64 years of age were compared with those 65 years or older. Between the two groups, total and weight-based propofol requirements for sedation, opioid doses, and adverse events were compared. This analysis included 101 procedural sedations. The median induction dose and opioid requirements before or during the procedure were not significantly different between the two groups. Compared with patients 18-64 years of age, those 65 years or older had significantly less total weight-based propofol requirements (p = 0.024) and required less total propofol for sedation (p = 0.007). In addition, patients 65 years or older required fewer repeat doses of propofol during the procedure than younger patients (p = 0.043). The incidence of adverse effects, including respiratory suppression, was not significantly different between the two groups. Patients 65 years or older may have lower weight-based propofol dosing requirements than younger patients. Utilizing a reduced total dose and repeat dosing strategy for propofol in this setting may be indicated. Further investigations are recommended to clarify factors that signal the need for more tailored dosing.

Can propofol procedural sedation implementation increase the acceptance of spinal anesthesia during cesarean section?

BackgroundParturients are highly anxious preoperatively. The worries of spinal anesthesia may preclude its acceptance despite being recommended. Procedural sedation is not a routine during regional blocks, but it is sensible that anesthesiologists should provide their blocks comfortably. The proposal is that implementing the propofol procedural sedation (PPS) may increase the acceptance rate of spinal anesthesia for cesarean section.MethodsIn this prospective observational study, the patients who refused spinal anesthesia primarily were interrogated to implement PPS for painless comfortable spinal anesthesia. Their acceptance rate was the primary outcome. In the sitting position, propofol 0.7 mg/kg and 20 mg increments were used as required. Patients were well supported and monitored. Data were compared by Mann-Whitney, chi-square, Fisher’s exact, and Friedman’s ANOVA tests as appropriate.ResultsThe acceptance rate of spinal anesthesia increased from 17 to 93%. During PPS, the mean values of minimal mean blood pressure were not significantly decreased, while the mean values of the heart rate slightly increased. The minimal values of oxygen saturation showed no significant reduction compared to the basal values. Patients expressed a marked relief of anxiety and high satisfaction.ConclusionThe use of propofol procedural sedation was effective in increasing the acceptance rate of spinal anesthesia during CS with safety and high patient’s satisfaction.

Propofol–midazolam versus propofol–dexmedetomidine as a deep sedation for endoscopic retrograde cholangio-pancreaticoduodenoscopy

Background Endoscopic retrograde cholangio-pancreaticoduodenoscopy (ERCP) is a day procedure for diagnostic or therapeutic biliary problems. Many kinds of sedation are used to provide patients comfort and facilitate work. Propofol and midazolam is the preferred cocktail. Dexmedetomidine with sedo-analgesic properties makes it another suitable regimen. The aim of this study was to compare the efficacy of adding either midazolam or dexmedetomidine to propofol for procedural sedation during ERCP. Patients and methods This study was conducted in Mansoura University Hospitals, Gastroenterology Center. A total of 84 patients (40–80 years), American Society of Anesthesiologist II, III, and IV scheduled for ERCP were randomly allocated into two groups: the PM group received propofol–midazolam and the group PD received propofol–dexmedetomidine. Heart rate, mean arterial blood pressure, and SpO2 were recorded at basal, intraoperative, postanesthesia care unit (PACU), till discharge. O2 desaturation, total dose of propofol, intraoperative complications, patients, and surgeon satisfaction were recorded. Results Heart rate and mean arterial blood pressure showed a significant reduction in group D compared with group M. Onset of deep sedation shows a significant reduction in group D versus group M. Recovery time and onset of discharge from the postanesthesia care unit shows statistically significant prolongation in group D versus group M. The total dose of propofol, intraoperative complications and also surgeon and patient satisfaction were comparable. Conclusion Administration of 1-μg/kg loading dose of dexmedetomidine or midazolam 1 mg intravenous, followed by intravenous propofol (1 mg/kg) and then 10 mg increments can produce an effective and smooth sedation without causing hemodynamic or respiratory side effects. So, dexmedetomidine could be an important alternative to midazolam for sedation in ERCP and other short procedures.

Procedural Sedation With Ketamine Versus Propofol for Closed Reduction of Pediatric Both Bone Forearm Fractures.

Effective treatment of pediatric both bone forearm fractures consists of timely restoration of anatomic alignment with manipulation and immobilization, often accomplished with the aid of procedural sedation in the emergency department setting. The current lack of consensus regarding a safe and optimal regimen may result in inadequate sedation, compromised quality of reduction, or patient harm. The current study was conducted to answer the following questions for pediatric both bone forearm fractures treated with closed reduction with either ketamine or propofol procedural sedation: (1) Is there a difference in the rate of unacceptable alignment 4 weeks after reduction? (2) Is there a difference in the rates of major sedation-related complications? Medical records, data on procedural sedation, and radiographs of 74 skeletally immature patients with diaphyseal or distal metaphyseal both bone forearm fractures treated with manipulation were reviewed (ketamine sedation, 26; propofol sedation, 48). Rates of unacceptable alignment for the 2 cohorts were similar both immediately after reduction and at 4 weeks. Rates of complications of procedural sedation did not differ between cohorts. The duration of procedural sedation was longer and the padding index was greater with ketamine. Malalignment after reduction was more likely in older patients and those with a higher padding index. Although no difference was found in the rates of malalignment or sedation-related complications between fractures reduced with ketamine or propofol sedation, the sedation regimens differ in both procedural duration and padding index. Careful consideration of the risks and benefits of procedural sedation for closed reduction of pediatric forearm fractures is warranted. [Orthopedics. 2017; 40(5):288-294.].

Comparison of bolus versus continuous infusion of propofol for procedural sedation: a meta-analysis

Objective: To compare the efficacy and safety of bolus infusion versus continuous infusion for propofol sedation.Methods: We searched OVID-MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Google Scholar, Koreamed, and Kmbase databases to identify all randomized controlled trials that compared bolus infusion with continuous infusion for propofol sedation. We evaluated propofol dose used, procedure, sedation, and recovery time. The incidences of respiratory and cardiovascular complications were also evaluated.Results: A total of 12 studies of 963 patients were included. The required propofol dose was significantly higher in continuous infusion compared with bolus infusion (standardized mean difference [SMD]: −0.44; 95% confidence interval [CI]: −0.71 to −0.16; I2 = 84%). Sedation time was significantly longer in continuous infusion compared with bolus infusion (mean difference [MD]: −8.58 min; 95% CI: −15.13 to −2.03; I2 = 44%). The recovery time and incidences of desaturation, airway intervention, hypotension, and bradycardia were comparable between bolus and continuous infusion.Conclusions: Propofol sedation by continuous infusion required a higher dose of propofol compared with bolus infusion, but the recovery time and frequency of complications were similar.

Pediatric Procedural Sedation Using the Combination of Ketamine and Propofol Outside of the Emergency Department: A Report From the Pediatric Sedation Research Consortium.

Outcomes associated with a sedative regimen comprised ketamine + propofol for pediatric procedural sedation outside of both the pediatric emergency department and operating room are underreported. We used the Pediatric Sedation Research Consortium database to describe a multicenter experience with ketamine + propofol by pediatric sedation providers. Prospective observational study of children receiving IV ketamine + propofol for procedural sedation outside of the operating room and emergency department using data abstracted from the Pediatric Sedation Research Consortium during 2007-2015. Procedural sedation services from academic, community, free-standing children's hospitals, and pediatric wards within general hospitals. Children from birth to less than or equal to 21 years old. None. A total of 7,313 pediatric procedural sedations were performed using IV ketamine + propofol as the primary sedative regimen. Median age was 84 months (range, < 1 mo to ≤ 21 yr; interquartile range, 36-144); 80.6% were American Society of Anesthesiologists-Physical Status less than III. The majority of sedation was performed in dedicated sedation or radiology units (76.1%). Procedures were successfully completed in 99.8% of patients. Anticholinergics (glycopyrrolate and atropine) or benzodiazepines (midazolam and lorazepam) were used in 14.2% and 41.3%, respectively. The overall adverse event and serious adverse event rates were 9.79% (95% CI, 9.12-10.49%) and 3.47% (95% CI, 3.07-3.92%), respectively. No deaths occurred. Risk factors associated with an increase in odds of adverse event included ASA status greater than or equal to III, dental suite, cardiac catheterization laboratory or radiology/sedation suite location, a primary diagnosis of having a gastrointestinal illness, and the coadministration of an anticholinergic. Using Pediatric Sedation Research Consortium data, we describe the diverse use of IV ketamine + propofol for procedural sedation in the largest reported cohort of children to date. Data from this study may be used to design sufficiently powered prospective randomized, double-blind studies comparing outcomes of sedation between commonly administered sedative and analgesic medication regimens.

Adverse Events During a Randomized Trial of Ketamine Versus Co-Administration of Ketamine and Propofol for Procedural Sedation in a Pediatric Emergency Department

BackgroundThe co-administration of ketamine and propofol (CoKP) is thought to maximize the beneficial profile of each medication, while minimizing the respective adverse effects of each medication. ObjectiveOur objective was to compare adverse events between ketamine monotherapy (KM) and CoKP for procedural sedation and analgesia (PSA) in a pediatric emergency department (ED). MethodsThis was a prospective, randomized, single-blinded, controlled trial of KM vs. CoKP in patients between 3 and 21 years of age. The attending physician administered either ketamine 1 mg/kg i.v. or ketamine 0.5 mg/kg and propofol 0.5 mg/kg i.v. The physician could administer up to three additional doses of ketamine (0.5 mg/kg/dose) or ketamine/propofol (0.25 mg/kg/dose of each). Adverse events (e.g., respiratory events, cardiovascular events, unpleasant emergence reactions) were recorded. Secondary outcomes included efficacy, recovery time, and satisfaction scores. ResultsNinety-six patients were randomized to KM and 87 patients were randomized to CoKP. There was no difference in adverse events or type of adverse event, except nausea was more common in the KM group. Efficacy of PSA was higher in the KM group (99%) compared to the CoKP group (90%). Median recovery time was the same. Satisfaction scores by providers, including nurses, were higher for KM, although parents were equally satisfied with both sedation regimens. ConclusionsWe found no significant differences in adverse events between the KM and CoKP groups. While CoKP is a reasonable choice for pediatric PSA, our study did not demonstrate an advantage of this combination over KM.

Comparison of Ketamine and Fentanyl with Propofol for Procedural Sedation and Analgesia for Dilatation and Curettage

Introduction: Dilatation and curettage (D&amp;C) is a common procedure that generally causes considerable pain and usually done under procedural sedation and analgesia. Propofol is an ideal intravenous anaesthtic agent for short interventional procedure like D&amp;C but lack of analgesia remains it’s main shortcoming therefore it is always combined with an analgesic. Ketamine and fentanyl are the popular analgesic in this context. Objectives: This prospective clinical study was designed to evaluate to compare propofol ketamine combination versus propofol fentanyl combination in respect of hemodynamics and recovery time for procedural sedation and analgesia in patients undergoing D&amp;C. Methods: This prospective randomized study was performed on 100 patients who underwent elective D&amp;C procedure. Patients were randomly allocated into two groups of fifty each: group PK received propofol 2mg/kg + ketamine 1mg/kg for induction and propofol 4mg/kg/hr + ketamine 1 mg/kg/hr for maintenance anesthesia, group PF received propofol 2 mg/kg + fentanyl 2 ìg/kg for induction and propofol 4 mg/kg/hr + fentanyl 1ìg/kg/hr for maintenance of anesthesia. The pulse rate, systolic and diastolic arterial blood pressures and peripheral oxygen saturation were recorded. Recovery times, side effects of sedation were also recorded. Results: Demographic data were found similar in two groups. There were no significant differences in heart rate, systolic and diastolic arterial blood pressure in all time intervals among groups except there was statistically significant fall in systolic blood pressure after induction in PF group (P=0.005). Recovery time was statistically significant increase in Group PK compared to Group PF (p=0.004). There were no significant differences among groups in regard to side effects. Conclusion: Propofol ketamine and propofol fentanyl had similar hemodynamic stability without any important side effects for procedural sedation and analgesia in patients underwent D&amp;C but propofol ketamine had longer recovery time. JBSA 2017; 30(1): 14-20

Effectiveness of remifentanil & propofol infusion for procedural sedation in patients undergoing gastrointestinal endoscopic procedures: a systematic review protocol

Effectiveness of remifentanil & propofol infusion for procedural sedation in patients undergoing gastrointestinal endoscopic procedures: a systematic review protocol

Propofol Procedural Sedation Is Safe

To determine the safety of propofol for emergency department (ED) procedural sedation, researchers retrospectively applied a sedation adverse-event reporting tool to 1008 consecutive patients (age range, 15 to 97 years) who underwent procedural sedation at a single ED in the U.K. over a 5-year period. Sentinel events included oxygen saturation <75% for any length of time or …

Propofol for Procedural Sedation in the Emergency Department: A Qualitative Systematic Review

To evaluate the efficacy and safety of propofol compared to other agents for procedural sedation of adults in the emergency department (ED) and to review the use of opioids in conjunction with propofol for procedural sedation in the ED. PubMed (1949-December 2012) and EMBASE (1980-December 2012) were searched using combinations of the following search terms: (procedural sedation or conscious sedation [MESH]) and propofol. A manual search of references was also performed. English-language, full reports of randomized controlled trials (RCTs) and observational studies evaluating propofol use in adults undergoing procedural sedation in the ED were included if they reported efficacy or safety outcomes. Two reviewers independently assessed each article for inclusion, data extraction, and study limitations. Thirteen RCTs and 20 observational studies meeting our inclusion criteria were retrieved. Regardless of the agent used for sedation, pro ce du ral success was greater than 80% and most trials demonstrated no statistically significant difference in the incidence of respiratory depression with propofol compared to alternatives. One RCT showed a significantly greater percent decrease in systolic blood pressure from baseline in those who received propofol compared to ketamine. Where reported, no significant difference was found in patient recall, pain, and satisfaction when opioids were added to propofol com pared to propofol alone; the addition of opioids may have resulted in a higher incidence of respiratory adverse events. Propofol for procedural sedation is a reasonable alternative for use in the ED, with comparative efficacy and safety to other alternatives. Use of opioids in addition to propofol may not provide added benefit but does contribute to increased rates of adverse events.

Propofol for Procedural Sedation and Analgesia Reduced Dedicated Emergency Nursing Time While Maintaining Safety in a Community Emergency Department

Procedural sedation and analgesia is a core competency in emergency medicine. Propofol is replacing midazolam in many emergency departments. Barriers to performing procedural sedation include resource utilization. We hypothesized that emergency nursing time is shorter with propofol than midazolam, without increasing complications. Retrospective analysis of a procedural sedation registry for two community emergency departments with combined census of 100,000 patients/year. Demographics, procedure, and ASA physical classification status of adult patients receiving procedural sedation between 2007-2010 with midazolam or propofol were analyzed. Primary outcome was dedicated emergency nursing time. Secondary outcomes were procedural success, ED length of stay, and complication rate. Comparative statistics were performed with Mann-Whitney, Kruskal-Wallis, chi-square, or Fisher's exact test. Linear regression was performed with log-transformed procedural sedation time to define predictors. Of 328 procedural sedation and analgesia, 316 met inclusion criteria, of which 60 received midazolam and 256 propofol. Sex distribution varied between groups (midazolam 3% male; propofol 55% male; P = 0.04). Age, procedure, and ASA status were not significantly different. Propofol had shorter procedural sedation time (propofol 32.5 ± 24.2 minutes; midazolam 78.7 ± 51.5 minutes; P < 0.001) and higher rates of procedural success (propofol 98%; midazolam 92%; P = 0.02). There were no significant differences between complication rates (propofol 14%; midazolam 13%; P = 0.88) or emergency department length of stay (propofol 262.5 ± 132.8 minutes; midazolam 288.6 ± 130.6 minutes; P = 0.09). Use of propofol resulted in shorter emergency nursing time and higher procedural success rate than midazolam with a comparable safety profile.

Use of propofol for procedural sedation reduces length of stay in the emergency department

Procedural sedation is used in the emergency department (ED) to facilitate short but painful interventions. Many patients are suitable for discharge after completion. Ideally, the agent used to achieve sedation should not have a prolonged effect, allowing safe discharge in the shortest time frame. We hypothesised that propofol, with its short onset and offset, may reduce length of stay (LOS) in comparison with traditional benzodiazepines.

Is procedural sedation safe by non-anesthesiologists?

To the Editor: Procedural sedation is a ‘‘state of sedation with a minimal depression of consciousness where the patient can tolerate unpleasant procedures but can maintain spontaneous respiration and airway-protective reflexes’’ [1]. In their recently published article in the Journal of Anesthesia (October 2012) that compared procedural sedation and general anesthesia, Hong and colleagues reported very serious findings on the use of procedural sedation by nonanesthesiologist sedation providers and their outcomes [2]. In this study, procedural sedation was provided by nonanesthesiologists in 88 % of the cases, with propofol being the sedating agent used in 84 % of cases, either alone or in combination. There was a complete lack of pre-procedural testing in 76 % of the cases. Five patients (20 %) did not receive any monitoring, and only 48 % received pulse oximetry monitoring during the procedure. Of the patients who underwent procedural sedation, 72 % died, with the most common cause of death being a respiratory event (72 % of cases). Hypoxia due to airway obstruction or respiratory depression and the inability to intubate and ventilate were the major reasons for respiratory events in those patients who underwent procedural sedation. These results are an eye-opener for the scientific community and further emphasize the importance of stricter guidelines for providing procedural sedation by non-anesthesiologists. The American College of Emergency Physicians recommends that individuals ‘‘providing procedural sedation and analgesia must have an understanding of the drugs administered, the ability to monitor the patient’s response to the medications given, and the skills necessary to intervene in managing all potential complications’’ [3]. Pre-procedural assessment and continuous monitoring of individuals undergoing procedural sedation is highly recommended [1, 3]. In another recent study, McGrane et al. reported a 4.7 % incidence of adverse events among patients who underwent procedural sedation with propofol [4]. These authors showed that the disciplined use of propofol by emergency physicians is safe and can be a viable option for procedural sedation [4]. However, further research is required to substantiate this evidence in the wake of revised administrative guidelines which have questioned the ability of emergency physicians to safely use propofol for procedural sedation [5]. The major reasons for such a high mortality and adverse events in the study by Hong et al. [2] could be the undisciplined use of propofol and the lack of knowledge on the part of sedation providers to anticipate impending respiratory events. Overall, propofol is a ‘‘safe but highly potent sedative agent and small alterations in serum concentration can cause swings in levels of consciousness and also produce cumulative sedation’’ [1]. Thus, an understanding of the pharmacological properties of propofol and the ability to monitor, intervene, and resuscitate if needed when complications do arise are a must for non-anesthesiologist sedation providers performing procedural sedation [1]. The study of Hong et al. [2] provides important evidence on the lack of knowledge and ability of sedation providers for procedural sedation and reiterates the importance of stricter guidelines for procedural sedation by non-anesthesiologists. Although this study is severely limited by selection bias, the evidence presented cannot be ignored. B. Singh (&) Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester 55905, MN, USA e-mail: singh.balwinder@mayo.edu

Age Is an Inverse Predictor of Propofol Dose for Procedural Sedation in Children

To determine if age predicts dosing of propofol in children, investigators retrospectively reviewed records of 88 patients aged <18 years (mean age, 11 years) who received only propofol for procedural sedation at a single emergency department between 2005 and 2009. Indications for sedation included …

Ketofol Causes Less Hypotension than Propofol Alone

Ketamine is a dissociative anesthetic agent with analgesic properties and inherent hemodynamic stability because it increases circulating catecholamine levels. It has been used in combination with propofol for procedural sedation, but few studies have directly compared the combination to propofol alone. These investigators compared the hemodynamic effects of ketofol …