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.

Alternative routes to intravenous procedural sedation to cardiovert unstable wide complex tachycardia – case report and review of literature

Background: Cardioversion is the treatment of choice in an unstable patient with arrhythmia. It requires analgesia and sedation, which is usually given via intravenous route. However, when there is a failure to get vascular access, alternatives routes to intravenous (IV) sedation and analgesia are needed. Case Presentation: A 59 year old male patient was presented to the emergency department (ED) complaining of chest pain and palpitation. His electrocardiogram (ECG) showed new onset rapid narrow complex atrial fibrillation, which then converted to wide complex tachycardia. Initially, the patient remained hemodynamically stable, but his blood pressure dropped, when cardioversion was indicated. In this case, intranasal (IN) and intraosseous (IO) routes were used, both of which are uncommon to be used for sedation in an unstable patient. The sedatives bioavailability and dosage via non intravenous (non-IV) routes are not commonly used, hence, literature was reviewed to find out the appropriate sedative dosage via non-IV routes specifically in IN and IO route for moderate sedation in ED, to facilitate procedures like cardioversion. Conclusion: It was believed that IN and IO routes are good alternatives to intravenous routes when timely vascular access can't be secured and when emergency medication administration is required.

Alternative routes to intravenous procedural sedation to cardiovert unstable wide complex tachycardia – case report and review of literature

Background: Cardioversion is the treatment of choice in an unstable patient with arrhythmia. It requires analgesia and sedation, which is usually given via intravenous route. However, when there is a failure to get vascular access, alternatives routes to intravenous (IV) sedation and analgesia are needed. Case Presentation: A 59 year old male patient was presented to the emergency department (ED) complaining of chest pain and palpitation. His electrocardiogram (ECG) showed new onset rapid narrow complex atrial fibrillation, which then converted to wide complex tachycardia. Initially, the patient remained hemodynamically stable, but his blood pressure dropped, when cardioversion was indicated. In this case, intranasal (IN) and intraosseous (IO) routes were used, both of which are uncommon to be used for sedation in an unstable patient. The sedatives bioavailability and dosage via non intravenous (non-IV) routes are not commonly used, hence, literature was reviewed to find out the appropriate sedative dosage via non-IV routes specifically in IN and IO route for moderate sedation in ED, to facilitate procedures like cardioversion. Conclusion: It was believed that IN and IO routes are good alternatives to intravenous routes when timely vascular access can't be secured and when emergency medication administration is required.

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

Safety and effectiveness of nitrous oxide procedural sedation in a paediatric emergency department

Dear Editor, Nitrous oxide (N2O) produces dissociative euphoria, amnesia and analgesia, and is a common sedative for procedural sedation in paediatric emergency departments (EDs) due to its non-parenteral administration and good safety profile.1-3 Suitable procedures include fracture reduction, toilet and suturing, incision and drainage, and application of burn dressings. The concentration of N2O administered ranges

“Effect of the SARS-COV-2 pandemic outbreak on the emergency department admission for an acute psychiatric condition”

Preliminary evidence seems to suggest a reduction in absolute terms of Emergency Department (ED) admissions for an acute psychiatric condition during the first months of the pandemic. The study aimed to test through a long-term time analysis the effect of COVID-19 on changes in ED visits for an acute psychiatric condition.A quasi-experimental interrupted time series analysis of admissions for acute psychiatric conditions to the Emergency Department of the Merano Hospital (Italy) was performed from January 2017 to August 2021. The main outcome was the monthly rate of ED accesses for an acute psychiatric condition reported per 1000 general admissions. The pandemic outbreak was used as an intervention point.4398 ED admissions for an acute psychiatric condition were registered. The rate of monthly admissions over total admissions increased from a mean of March 17, 1000 (SD 2.9) admissions per month in the pre-COVID-19 era to September 22, 1000 (SD 4.5) in the pandemic months, p < 0.001. In March 2020, the pandemic outbreak led to a significant increase in ED visits for an acute psychiatric condition (p = 0.013) and suicide attempts (p = 0.029), and to an increased need for pharmacological sedation in ED (p = 0.001). During the pandemic, although admissions and hospitalizations showed a non-significant decreasing trend, suicide attempts increased steadily and significantly.The outbreak of the COVID-19 pandemic caused a major increase in rates of admission to the ED for an acute psychiatric condition.

The Feasibility of Implementing Targeted SEDation in Mechanically Ventilated Emergency Department Patients: The ED-SED Pilot Trial.

Deep sedation in the emergency department (ED) is common, increases deep sedation in the ICU, and is negatively associated with outcome. Limiting ED deep sedation may, therefore, be a high-yield intervention to improve outcome. However, the feasibility of conducting an adequately powered ED-based clinical sedation trial is unknown. Our objectives were to assess trial feasibility in terms of: 1) recruitment, 2) protocol implementation and practice change, and 3) safety. Patient-centered clinical outcomes were assessed to better plan for a future large-scale clinical trial. Pragmatic, multicenter ( n = 3), prospective before-after pilot and feasibility trial. The ED and ICUs at three medical centers. Consecutive, adult mechanically ventilation ED patients. An educational initiative aimed at reliable ED sedation depth documentation and reducing the proportion of deeply sedated patients (primary outcome). Sedation-related data in the ED and the first 48 ICU hours were recorded. Deep sedation was defined as a Richmond Agitation-Sedation Scale of -3 to -5 or a Sedation-Agitation Scale of 1-3. One thousand three hundred fifty-six patients were screened; 415 comprised the final population. Lighter ED sedation was achieved in the intervention group, and the proportion of deeply sedated patients was reduced from 60.2% to 38.8% ( p < 0.01). There were no concerning trends in adverse events (i.e., inadvertent extubation, device removal, and awareness with paralysis). Mortality was 10.0% in the intervention group and 20.4% in the preintervention group ( p < 0.01). Compared with preintervention, the intervention group experienced more ventilator-free days [22.0 (9.0) vs 19.9 (10.6)] and ICU-free days [20.8 (8.7) vs 18.1 (10.4)], p < 0.05 for both. This pilot trial confirmed the feasibility of targeting the ED in order to improve sedation practices and reduce deep sedation. These findings justify an appropriately powered clinical trial regarding ED-based sedation to improve clinical outcomes.

Prospective study of haloperidol plus lorazepam versus droperidol plus midazolam for the treatment of acute agitation in the emergency department

Study objectivesThe objective of this study was to compare the combination of intramuscular (IM) droperidol/midazolam to haloperidol/lorazepam regarding time to sedation in patients with acute undifferentiated agitation in the emergency department (ED). MethodsThis was a prospective, unblinded observational study in the ED of a university teaching hospital. Subjects with acute undifferentiated agitation refractory to verbal de-escalation were assigned to receive a combination of either haloperidol 5 mg/lorazepam 2 mg or droperidol 5 mg/midazolam 5 mg IM. The primary outcome was the proportion of patients adequately sedated at 10 min defined as ED Sedation Assessment Tool (SAT) score of 0 or less. Secondary outcomes included change in ED SAT score at 5, 15, 30, and 60 min, the need for oxygen supplementation, and the need for airway intervention. ResultsA total of 86 patients were enrolled in the study, with 43 patients receiving droperidol/midazolam and 43 patients receiving haloperidol/lorazepam. Ten minutes after receiving medication, 51.2% of patients in the droperidol/midazolam group were adequately sedated compared to 7% of patients in the haloperidol/lorazepam group (OR: 14; 95% CI: 3.7, 52.1). Median time to adequate sedation was 10 min for the droperidol/midazolam group and 30 min for the haloperidol/lorazepam group. Eleven patients (25.6%) in the droperidol/midazolam group received oxygen supplementation compared to four patients (9.3%) in the haloperidol/lorazepam group. No study patients experienced extrapyramidal symptoms or required endotracheal intubation. ConclusionIntramuscular droperidol/midazolam was superior to intramuscular haloperidol/lorazepam in achieving adequate sedation at 10 min. Patients in the droperidol/midazolam arm may be more likely to receive oxygen supplementation than those in the haloperidol/lorazepam arm.

Prehospital Ketamine Administration for Excited Delirium with Illicit Substance Co-Ingestion and Subsequent Intubation in the Emergency Department.

Excited delirium, which has been defined as combativeness, agitation, and altered sensorium, requires immediate treatment in prehospital or emergency department (ED) settings for the safety of both patients and caregivers. Prehospital ketamine use is prevalent, although the evidence on safety and efficacy is limited. Many patients with excited delirium are intoxicated with illicit substances. This investigation explores whether patients treated with prehospital ketamine for excited delirium with concomitant substance intoxication have higher rates of subsequent intubation in the ED compared to those without confirmed substance usage. Over 28 months at two large community hospitals, all medical records were retrospectively searched for all patients age 18 years or greater with prehospital ketamine intramuscular (IM) administration for excited delirium and identified illicit and prescription substance co-ingestions. Trained abstractors collected demographic characteristics, history of present illness (HPI), urine drug screens (UDS), alcohol levels, and noted additional sedative administrations. Substance intoxication was determined by UDS and alcohol positivity or negativity, as well as physician HPI. Patients without toxicological testing or documentation of substance intoxication, or who may have tested positive due to ED sedation, were excluded from relevant analyses. Subsequent ED intubation was the primary pre-specified outcome. Odds ratios (OR) and 95% confidence intervals (CI) were calculated to compare variables. Among 86 patients given prehospital ketamine IM for excited delirium, baseline characteristics including age, ketamine dose, and body mass index were similar between those who did or did not undergo intubation. Men had higher intubation rates. Patients testing positive for alcohol, amphetamines, barbiturates, benzodiazepines, ecstasy, marijuana, opiates, and synthetic cathinones, both bath salts and flakka, had similar rates of intubation compared to those negative for these substances. Of 27 patients with excited delirium and concomitant cocaine intoxication, nine (33%) were intubated compared with four of 50 (8%) without cocaine intoxication, yielding a 5.75 OR (95%, CI 1.57 to 21.05; P = .009). Patients treated with ketamine IM for excited delirium with concomitant cocaine intoxication had a statistically significant 5.75-fold increased rate of subsequent intubation in the ED. Amongst other substances, no other trends with intubation were noted, but further study is warranted.

Documentation of Procedural Sedation by Emergency Physicians.

IntroductionPatients presenting to the emergency department (ED) frequently require procedural sedation and analgesia (PSA) to facilitate procedures, such as joint reduction. Proper documentation of screening demonstrates awareness of the necessity of presedation assessment. It is unknown if introducing emergency physicians (EPs) at the ED improves presedation assessment and documentation. In this study the differences in documentation of ED sedation and success rates for reduction of hip dislocations in the presence versus absence of EPs are described.MethodsIn this retrospective descriptive study, we analyzed data of patients presenting with a dislocated hip post total hip arthroplasty (THA) shortly after the introduction of EPs. The primary outcome measure was the presence of documentation of presedation assessment. Secondary outcomes were documentation of medication, vital signs, and success rate of hip reductions.ResultsIn the two-year study period, 133 sedations for hip reductions were performed. Sixty-eight sedations were completed by an EP. The documentation of fasting status, airway screening, analgesia use, and vital signs was documented significantly more often when an EP was present (respectively 64.9%, 80.3%, 37.4%, and 72.7%, all P < 0.001). There was no difference in success rate of hip reductions between the groups.ConclusionPSA in the ED is associated with superior documentation of presedation assessment, medication, and vital signs when EPs are involved.

Pediatric procedural sedation and analgesia in the emergency department: surveying the current European practice

Procedural sedation and analgesia outside the operating theater have become standard care in managing pain and anxiety in children undergoing diagnostic and therapeutic procedures. The objectives of this study are to describe the current pediatric procedural sedation and analgesia practice patterns in European emergency departments, to perform a needs assessment-like analysis, and to identify barriers to implementation. A survey study of European emergency departments treating children was conducted. Through a lead research coordinator identified through the Research in European Pediatric Emergency Medicine (REPEM) network for each of the participating countries, a 30-question questionnaire was sent, targeting senior physicians at each site. Descriptive statistics were performed. One hundred and seventy-one sites participated, treating approximately 5 million children/year and representing 19 countries, with a response rate of 89%. Of the procedural sedation and analgesia medications, midazolam (100%) and ketamine (91%) were available to most children, whereas propofol (67%), nitrous oxide (56%), intranasal fentanyl (47%), and chloral hydrate (42%) were less frequent. Children were sedated by general pediatricians in 82% of cases. Safety and monitoring guidelines were common (74%), but pre-procedural checklists (51%) and capnography (46%) less available. In 37% of the sites, the entire staff performing procedural sedation and analgesia were certified in pediatric advanced life support. Pediatric emergency medicine was a board-certified specialty in 3/19 countries. Physician (73%) and nursing (72%) shortages and lack of physical space (69%) were commonly reported as barriers to procedural sedation and analgesia. Nurse-directed triage protocols were in place in 52% of the sites, mostly for paracetamol (99%) and ibuprofen (91%). Tissue adhesive for laceration repair was available to 91% of children, while topical anesthetics for intravenous catheterization was available to 55%. Access to child life specialists (13%) and hypnosis (12%) was rare.Conclusion: Procedural sedation and analgesia are prevalent in European emergency departments, but some sedation agents and topical anesthetics are not widely available. Guidelines are common but further safety nets, nurse-directed triage analgesia, and nonpharmacologic support to procedural sedation and analgesia are lacking. Barriers to implementation include availability of sedation agents, staff shortage, and lack of space.What is Known:• Effective and prompt analgesia, anxiolysis, and sedation (PSA) outside the operating theatre have become standard in managing pain and anxiety in children undergoing painful or anxiogenic diagnostic and therapeutic procedures.• We searched PubMed up to September 15, 2020, without any date limits or language restrictions, using different combinations of the MeSH terms “pediatrics,” “hypnotics and sedatives,” “conscious sedation,” and “ambulatory surgical procedures” and the non-MeSH term “procedural sedation” and found no reports describing the current practice of pediatric PSA in Europe.What is New:• This study is, to the best of our knowledge, the first to shed light on the pediatric PSA practice in European EDs and uncovers important gaps in several domains, notably availability of sedation medications and topical anesthetics, safety aspects such as PSA provider training, availability of nonpharmacologic support to PSA, and high impact interventions such as nurse-directed triage analgesia.• Other identified barriers to PSA implementation include staff shortage, control of sedation medications by specialists outside the emergency department, and lack of space.

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.

Hunger Games: Impact of Fasting Guidelines for Orthopedic Procedural Sedation in the Pediatric Emergency Department.

Fasting guidelines for pediatric procedural sedation have historically been controversial. Recent literature suggests that there is no difference in adverse events regardless of fasting status. The goal of this study was to examine adverse outcomes and departmental efficiency when fasting guidelines are not considered during pediatric emergency department (PED) sedation for orthopedic interventions. Retrospective chart review identified 2674 patients who presented to a level I PED and required procedural sedation for orthopedic injuries between February 2011 and July 2018. This was a level III, retrospective cohort study. Patients were categorized into the following groups: already within American Society of Anesthesiologists (ASA) fasting guidelines on presentation to the PED (n=671 [25%]), had procedural sedation not within the ASA guidelines (n=555 [21%]), and had procedural sedation after fasting in the PED to meet ASA guidelines (n=1448 [54%]). Primary outcomes were length of stay, time from admission to start of sedation, length of sedation, time from end of sedation to discharge, and adverse events. There was a significant difference in the length of stay and time from admission to sedation-both approximately 80min longer in those with procedural sedation after fasting in the PED to meet ASA guidelines (p<0.001). There was no significant difference among groups in length of sedation or time to discharge after sedation. Adverse events were uncommon, with only 55 total adverse events (0.02%). Vomiting during the recovery phase was the most common (n=17 [0.006%]). Other notable adverse events included nine hypoxic events (0.003%) and five seizures (0.002%). There was no significant difference in adverse events among the groups. Length of stay in the PED was significantly longer if ASA fasting guidelines were followed for children requiring sedation for orthopedic procedures. This is a substantial delay in a busy PED where beds and resources are at a premium. Although providing similar care with equivalent outcomes, the value of spending less time in the PED is evident. Overall, adverse events related to sedation are rare and not related to fasting guidelines.

Propofol Target-Controlled Infusion in Emergency Department Sedation (ProTEDS): a multicentre, single-arm feasibility study

BackgroundProcedural sedation is a core skill of the emergency physician. Bolus administration of propofol is widely used in UK EDs. Titrated to an end point of sedation, it has a...

A study protocol for a multicentre, prospective, before-and-after trial evaluating the feasibility of implementing targeted SEDation after initiation of mechanical ventilation in the emergency department (The ED-SED Pilot Trial)

IntroductionSedation is a cornerstone therapy in the management of patients receiving mechanical ventilation and is highly influential on outcome. Early sedation depth appears especially influential, as early deep sedation is...

116 Associations of Emergency Department Sedation and Analgesia and Hospital Outcomes in Mechanically Ventilated Patients

116 Associations of Emergency Department Sedation and Analgesia and Hospital Outcomes in Mechanically Ventilated Patients

Midazolam, Etomidate, Propofol, Fentanyl, Ketamine, and Propofol/Ketamine for Procedural Sedation and Analgesia Among Adults in the Emergency Departments: A Systematic Review

: The current systematic review aimed at investigating different medications commonly used for procedural sedation and analgesia (PSA) in emergency departments (EDs) for adults. The articles related to the subject of interest were searched in five electronic databases, including Google Scholar, PubMed, Medline, Web of Science, Scopus, and Embase, up to 2019. The blinded, randomized, controlled, clinical trials comparing common PSA medications, including midazolam, etomidate, propofol, fentanyl, ketamine, and ketofol, among the adults undergoing PSA in EDs were included in the study. The search process resulted in the inclusion of 35 papers in the study. The main information, including clinical features, sedation duration, recovery time, and incidence of adverse events, was extracted from the selected studies. Based on the reviewed studies, various combinations of medications are used for PSA depending on the hospital protocols and policies; however, there is still controversy over the best choice. As the results of the retrieved articles indicated, propofol is the most common medication used for PSA in EDs due to the shorter time of induction, rapid recovery of consciousness, and fewer side effects. Etomidate and ketamine were also identified as other common sedatives applied for PSA.

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.

Availability and quality of procedural sedation and analgesia in emergency departments without emergency physicians: A national survey in the Netherlands.

Emergency physicians have been successful in implementing procedural sedation and analgesia (PSA) to treat emergency department (ED) patients who need to undergo painful procedures. However, 25% of the EDs in the Netherlands are not staffed by emergency physicians. The aim of this study was to investigate PSA availability and quality in EDs without emergency physicians. We performed an exploratory cross-sectional study amongst ED nurses and physicians in all 13 EDs without emergency physicians in the Netherlands. Data were gathered using a standardized questionnaire. The response rate was 34.3% (148/432). Of the respondents, 84/148 (56.8%) provided adult PSA and 30/148 (20.3%) provided paediatric PSA. Main reasons for not providing PSA were insufficient numbers of trained staff to support PSA in the ED and insufficient training and exposure. The providers agreed significantly stronger when reflecting their PSA competencies in adults compared to paediatric patients. The key to improve pain management in the ED-setting may lay in investing in continuous training of ED health care professionals and/or acquiring professionals who are both qualified in PSA and available in the ED.