Sedation In Emergency Department Research Articles

152 Adverse Events in Pediatric Patients Undergoing Procedural Sedation in a General Emergency Department

Procedural sedation is recommended as a way to decrease a patient's pain during a procedure. Failure to treat pain adequately has many negative consequences, including increased difficulty treating subsequent episodes of pain, increased risk of chronic pain, increased costs, and worse clinical outcomes. In spite of the many benefits of procedural sedation, the use of procedural sedation in the emergency department (ED) by emergency physicians has been questioned, especially in pediatric patients. Whether procedural sedation of infants and children can be safe and effective when done in a general emergency department where all ages of patients (eg, both adult and pediatric patients) are evaluated and treated) compared to a pediatric ED where only infants and children are treated has also been debated. Furthermore, there has not been a lot of data regarding procedural sedation in infants and children in a general ED. The objective of this study is to determine the incidence and types of adverse effects on procedural sedation in pediatric patients in a general ED. Prospective data collection of all pediatric patients (age < 22 years) undergoing procedural sedation in the ED on a standardized hospital-wide quality improvement (QI) form over 10 years. Data was analyzed by SPSS. There were 857 cases of procedural sedation in pediatric patients (age < 22 years), mean age 8.5 years, range 2 weeks to 21 years. The incidence of adverse events was only 4.4%. The adverse events included hypotension 1.5% (13/857), hypoxia (oxygen saturation < 90%) 0.8% (7/857), bradypnea/apnea 0.7% (6/857) and allergic reaction 0.001% (1/657). Other adverse events included cough, hiccups and emergence reaction. All patients responded well to simple measures such as repositioning of the head, supplemental oxygen and bag-valve mask for a very short period of time. There were no deaths, no intubations, no incidence of aspiration pneumonia, no inpatient hospitalizations, and no permanent morbidity in any of the patients. Only 1 patient was observed overnight in the ED observation unit due to an emergence reaction from ketamine and was well (symptom free) prior to discharge. The most common reasons for sedation were fracture reduction of a dislocated joint, laceration/wound repair, lumbar puncture, incision and drainage of an abscess. Pediatric sedation can be done safely in a general ED for a wide variety of procedures. The incidence of adverse events for pediatric patients undergoing procedural sedation in a general ED is similar to that for pediatric patients undergoing procedural sedation in a pediatric ED (in a freestanding Childrens Hospital). This suggests that concerns about the safety of emergency physicians doing procedural sedation, including emergency physicians doing procedural sedation in infants and children in a general emergency department, are unfounded.

The Utility of High-Flow Oxygen During Emergency Department Procedural Sedation and Analgesia With Propofol: A Randomized, Controlled Trial

We determine whether high-flow oxygen reduces the incidence of hypoxia by 20% in adults receiving propofol for emergency department (ED) sedation compared with room air. We randomized adults to receive 100% oxygen or compressed air at 15 L/minute by nonrebreather mask for 5 minutes before and during propofol procedural sedation. We administered 1.0 mg/kg of propofol, followed by 0.5 mg/kg boluses until the patient was adequately sedated. Physicians and patients were blinded to the gas used. Hypoxia was defined a priori as an oxygen saturation less than 93%; respiratory depression was defined as an end tidal CO(2) greater than 50 mm Hg, a 10% absolute change from baseline, or loss of waveform. We noted significantly less hypoxia in the 59 patients receiving high-flow oxygen compared with the 58 receiving compressed air (19% versus 41%; P=.007; difference 23%; 95% confidence interval 6% to 38%). Respiratory depression was similar between groups (51% versus 48%; difference 2%; 95% confidence interval -15% to 22%). We observed 2 adverse events in the high-flow group (1 hypotension, 1 bradycardia) and 2 in the compressed air group (1 assisted ventilation, 1 hypotension). High-flow oxygen reduces the frequency of hypoxia during ED propofol sedation in adults.

Journal Scan: Benzodiazepines Reduce Ketamine-Related Emergence Reactions in Adults

Journal Scan: Benzodiazepines Reduce Ketamine-Related Emergence Reactions in Adults

Factors associated with failure to successfully complete a procedure during emergency department sedation

To determine factors associated with failure to successfully complete a procedure during sedation in the ED. Eleven Australian EDs enrolled consecutive adult and paediatric patients between January 2006 and December 2008. Patients were included if a sedative drug was administered for an ED procedure and the success or failure of the procedure was recorded. Data were available for 2567 patients. Of these, 1548 (60.3%, 95% CI 58.4-62.2) were male and 456 (17.8%, 95% CI 16.3-19.3) were age <16 years. The most common procedures performed were reduction of major joints and laceration repair. A total of 149 procedures (5.8%, 95% CI 5.0-6.8) failed. There were significant differences in failure rates between the types of procedure undertaken, with reduction of hips, digits and mandibles associated with the highest failure rates (P < 0.001). In adults, body weight >100 kg was also associated with increased risk of procedural failure (odds ratio 2.3, 95% CI 1.3-4.1). Ketamine used as a single agent had the lowest procedural failure rate (2.5%, 95% CI 1.1-5.4) whereas propofol had the highest (5.9%, 95% CI 4.6-7.6). However, these two drugs were generally used in different age groups and for different procedures. Procedures performed under sedation in the ED have a low failure rate. However, increased body weight and specific procedures, such as hip reduction, are associated with significantly higher failure rates. Special consideration should be given to these patient groups before undertaking sedation in the ED.

Sédation avec le propofol dans un service d’urgences. Étude prospective observationnelle

IntroductionWe describe the use of propofol for procedural sedation and analgesia (PSA) in a French adult Emergency Department (ED). We compare the results with those previously published.Materials and methodsA 44-month prospective observational study of the use of propofol in a French adult ED was conducted. Propofol was injected intravenously as a 1 mg/kg bolus, which could be followed by smaller aliquots if necessary. All patients were monitored for at least 30 minutes after the last injection.ResultsAmong the 115 patients who received propofol for PSA during the study period, 111 (69 males and 42 females) were completely evaluated. The mean age was 50 (SD: 21; range: 18–94), mean body weight was 75 kg (SD: 15; range: 48–140), mean total propofol dosing was 113 mg (SD: 58; range: 30–370), and mean propofol dosing per kg was 1.50 mg/kg (SD: 0.75; range: 0.5–5.6 mg/kg). The treatment was successful in 107/111 cases (97%). If hypotension or respiratory depression occurred, they were resolved in minutes. There were no cases of emesis, inhalation, or other side effects. These results compare favorably with those previously published.ConclusionPropofol is a useful and safe tool for PSA in French EDs, as it is elsewhere.

Procedural sedation and analgesia in a large UK Emergency Department: factors associated with complications

BackgroundThe aim of this study was to investigate the delivery of procedural sedation and analgesia (PSA) in an urban teaching hospital Emergency Department (ED) over a 2-year period, and identify...

Ketamine With and Without Midazolam for Emergency Department Sedation in Adults: A Randomized Controlled Trial

We assess whether midazolam reduces recovery agitation after ketamine administration in adult emergency department (ED) patients and also compared the incidence of adverse events (recovery agitation, respiratory, and nausea/vomiting) by the intravenous (IV) versus intramuscular (IM) route. This prospective, double-blind, placebo-controlled, 2×2 factorial trial randomized consecutive ED patients aged 18 to 50 years to 4 groups: receiving either 0.03 mg/kg IV midazolam or placebo, and with ketamine administered either 1.5 mg/kg IV or 4 mg/kg IM. Adverse events and sedation characteristics were recorded. Of the 182 subjects, recovery agitation was less common in the midazolam cohorts (8% versus 25%; difference 17%; 95% confidence interval [CI] 6% to 28%; number needed to treat 6). When IV versus IM routes were compared, the incidences of adverse events were similar (recovery agitation 13% versus 17%, difference 4%, 95% CI -8% to 16%; respiratory events 0% versus 0%, difference 0%, 95% CI -2% to 2%; nausea/vomiting 28% versus 34%, difference 6%, 95% CI -8% to 20%). Coadministered midazolam significantly reduces the incidence of recovery agitation after ketamine procedural sedation and analgesia in ED adults (number needed to treat 6). Adverse events occur at similar frequency by the IV or IM routes.

Sedation of children in the emergency department for short painful procedures compared with theatre, how much does it save? Economic evaluation

IntroductionSedation of children for short painful procedures is increasingly performed in emergency departments as an alternative to hospital admission and theatre. In this study, the savings of this are sought...

A Randomized Controlled Trial Comparing Patient-Controlled and Physician-Controlled Sedation in the Emergency Department

We compare patient-controlled sedation (PCS) and emergency physician-controlled sedation (EPCS) with respect to propofol requirements, depth of sedation, adverse events, recovery time, physician satisfaction, and patient satisfaction in emergency department (ED) patients requiring brief but painful procedures. One hundred sixty-six patients in this randomized controlled trial received propofol sedation according to one of 2 regimens: infusion of propofol at doses determined by the treating physician (EPCS group) or infusion of propofol with a patient-controlled infusion pump (PCS group). The PCS group received an initial physician-controlled bolus following by self-administered doses. Depth of sedation was assessed at 3-minute intervals. Adverse events were recorded as they occurred. Physician and patient satisfaction were recorded with 100-mm visual analog scales. There was a nonsignificant trend toward lower total propofol doses with PCS relative to EPCS (medians 1.36 versus 1.60 mg/kg, respectively; median difference -0.15 mg/kg; 95% confidence interval of the difference -0.33 to 0.05 mg/kg; P=.14). Adverse events, requirement for treatment of adverse events, and recovery time did not differ in the 2 groups. Depth of sedation was lower in the PCS group. Procedural success, ease of procedure, and patient satisfaction were similar in both groups despite nearly twice as many patients recalling the procedure in the PCS group and 15% of patients requiring additional physician-administered doses in the PCS group. Compared with EPCS, PCS demonstrated similar propofol dosing, safety, recovery, and satisfaction but resulted in lighter sedation. Propofol PCS appears safe and effective for ED procedures requiring moderate rather than deep sedation.

Intravenous Thiamylal and Local Anesthetic Infiltration for Pediatric Facial Repair Procedures Performed in Emergency Departments

Thiamylal is widely used for procedural sedation in emergency departments (ED); however, there are limited safety data for doses of thiamylal > 5 mg/kg in children. We investigated whether intravenous thiamylal in combination with local anesthetics is safe and effective for pediatric procedural sedation in the ED and to identify the association between increasing doses thiamylal and adverse events. Between July 2004 and June 2008, 227 children who underwent procedural sedation met the inclusion criteria, including 105 males (46.3%) and 122 females (53.7%). Facial laceration was the most common indication for procedural sedation. All children received an intravenous injection of thiamylal, with a loading dose of 5 mg/kg. Eighty-one children (35.7%) received a supplemental dose of 2.5 mg/kg thiamylal because of inadequate sedation. Of these, 27 (11.9%) received a second supplemental dose of 2.5 mg/kg because of inadequate sedation. Sixty-six patients (29.1%) experienced 75 mild and self-resolving adverse events, and most of which (15/75; 20%) were drowsiness. Four (1.8%) patients experienced oxygen saturation below 96%, which was related to the supplemental dose of thiamylal (p = 0.002). No children suffered from any lasting or potentially serious complications. Our results indicate that intravenous thiamylal in combination with local anesthetic infiltration is a well tolerated for therapeutic procedures in the ED. Thiamylal offers rapid onset of sedation without compromising the patient's cardiorespiratory function during pediatric procedural sedation.

Total Procedural Requirements as Indication for Emergency Department Sedation

Indications for pediatric procedural sedation and analgesia are generally based on the need to manage pain or elicit cooperation for a single major procedure in the emergency department setting. However, multiple minor procedures such as vascular access, urethral catheterization, lumbar puncture, or superficial abscess drainage may be required in the care of a single child, and combining these activities may produce as much stress as a single major procedure. The use of procedural sedation in children based on total procedural requirements is proposed with 2 illustrative cases as examples of this concept.

Procedural sedation analgesia

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

Is Higher ASA Class Associated With an Increased Incidence of Adverse Events During Procedural Sedation in a Pediatric Emergency Department?

To prospectively investigate whether American Society of Anesthesiologists (ASA) class, as assigned by nonanesthesiologists, is associated with adverse events during procedural sedation in a pediatric emergency department. A prospectively collected database of children aged 0 to 21 years undergoing procedural sedation in the emergency department of an urban, tertiary care, children's hospital was retrospectively reviewed. This database included clinical and demographic characteristics, including assigned ASA class. It also included information relative to the procedure, the sedation, and any complications related to the sedation. Complications were defined a priori as persistent oxygen desaturation to less than 93% on pulse oximetry requiring supplemental oxygen, bronchospasm, dizziness, apnea, seizure, hiccoughs, laryngospasm, stridor, arrhythmia, hypotension, rash, vomiting, aspiration, or a disinhibition/agitation/dysphoria emergence reaction. Main outcome measure was the incidence of complications relative to ASA class. Procedural sedation was performed in the emergency department 1232 times during the study period; 30 sedations did not have either ASA class or occurrence of a complication recorded. Thus, 1202 sedations were included in the study. Nine hundred eighty-eight patients were classified as ASA class 1, whereas 214 were classified as ASA class 2 or greater. There were a total of 215 adverse events in the study population. Most of these were hypoxia (185 total) and were more likely to occur in patients with an ASA class 2 or greater (P = 0.021). Adverse events during procedural sedation are more common in patients with higher ASA class.

Does End Tidal CO 2 Monitoring During Emergency Department Procedural Sedation and Analgesia With Propofol Decrease the Incidence of Hypoxic Events? A Randomized, Controlled Trial

We determine whether the use of capnography is associated with a decreased incidence of hypoxic events than standard monitoring alone during emergency department (ED) sedation with propofol. Adults underwent ED propofol sedation with standard monitoring (pulse oximetry, cardiac and blood pressure) and capnography and were randomized into a group in which treating physicians had access to the capnography and a blinded group in which they did not. All patients received supplemental oxygen (3 L/minute) and opioids greater than 30 minutes before. Propofol was dosed at 1.0 mg/kg, followed by 0.5 mg/kg as needed. Capnographic and SpO2 data were recorded electronically every 5 seconds. Hypoxia was defined as SpO2 less than 93%; respiratory depression, as end tidal CO2 (ETCO2) greater than 50 mm Hg, ETCO2 change from baseline of 10%, or loss of the waveform. One hundred thirty-two subjects were evaluated and included in the final analysis. We observed hypoxia in 17 of 68 (25%) subjects with capnography and 27 of 64 (42%) with blinded capnography (P=.035; difference 17%; 95% confidence interval 1.3% to 33%). Capnography identified all cases of hypoxia before onset (sensitivity 100%; specificity 64%), with the median time from capnographic evidence of respiratory depression to hypoxia 60 seconds (range 5 to 240 seconds). In adults receiving ED propofol sedation, the addition of capnography to standard monitoring reduced hypoxia and provided advance warning for all hypoxic events.

ORAL MIDAZOLAM FOR DEMENTIA‐RELATED RESPONSE AGITATION

To the Editor: Patients with moderate to severe dementia commonly develop agitation and aggression in response to personal care. Response agitation is a distressing problem that can endanger the patient and caregivers and that often persists despite identification and correction of factors that trigger the agitation. Behavioral and environmental strategies to manage dementia-related response agitation are often ineffective, and medications commonly used to manage dementia-related response agitation are increasingly being found to have specific risks in patients with dementia. Although often effective for short-term management of severe agitation, use of antipsychotic medications in patients with dementia has been associated with risk of serious adverse effects, including stroke,1 pneumonia,2 and death.1 Among other risks, benzodiazepine use in patients with dementia often causes daytime oversedation owing to the half-life of even commonly used short-acting agents (lorazepam, 9–16 hours; oxazepam, 4–14 hours; temazepam, 8–20 hours).3 Regular use of antipsychotic medications or benzodiazepines such as lorazepam for the management of dementia-related response agitation is therefore often unsafe and impractical. The case of a patient suffering from severe dementia with refractory response aggression that remitted with the use of oral midazolam is presented. A 93-year-old woman with a history of dementia of the Alzheimer's type in the severe stages was admitted to a geriatric psychiatry ward for assessment and management of severe aggression and agitation during personal care. The patient presented with extended care needs; she was unable to walk or transfer independently, requiring total assistance for basic activities of daily living, and flexion contractures had developed in her arms and legs. She directed severe agitation and aggression toward nursing staff during toileting, bathing, and transfers but remained calm when unattended during the remainder of the day and slept well most nights. Rigorous nursing care planning and environmental and behavioral management strategies were ineffective. Identification and treatment of potential triggers such as pain failed to extinguish the agitation and aggression. Management of pain included injection of flexion contractures with Botox by a physiatrist and gabapentin titrated up to the maximum tolerated dose (600 mg twice a day) in addition to regular dosing of acetaminophen 1,000 mg every 6 hours. The patient had a disappointing response to pharmacotherapy specifically targeting response agitation. This included quetiapine up to 150 mg daily (ineffective and oversedating), citalopram up to 30 mg daily (ineffective), a low dose of zuclopenthixol (a 72-hour depot-typical antipsychotic; 5 mg intramuscularly) (caused severe extrapyramidal side-effects), pre-care lorazepam use at the minimum effective dose (caused 6–8 hours or more of daytime oversedation), and olanzapine (pre-care use was ineffective and oversedating). Midazolam oral solution was prepared at a concentration of 2 mg/mL. The dosage was started at 2 mg and titrated gradually (over the course of 2 weeks) up to 6 mg given 15 to 30 minutes before personal care or transfers. The patient's response agitation and aggression resolved with no consequent daytime oversedation, and all antipsychotics were discontinued. Midazolam3 is an ultra-brief-acting benzodiazepine with a half-life of 1.5 to 6 hours. It is commonly used for conscious sedation in emergency departments, in minor procedures such as endoscopy,4 and for uncooperative patients such as in pediatric dentistry.5 It has an oral bioavailability of 35% to 40% when given orally and greater than 90% when given parenterally. Parenteral routes are usually limited to emergency department and intensive care settings. Dosage reductions are required with parenteral administration. It undergoes hepatic metabolism and renal excretion. In this patient, the use of oral midazolam was associated with marked improvement in severe dementia-related response agitation. Based on this case study, preparation of a midazolam oral solution with a concentration of 2 to 3 mg/mL is recommended. Nursing staff should be requested to shake the solution to ensure proper constitution before administration. Starting at a dose of 1 to 2 mg given orally 15 to 30 minutes before personal care or transfers is suggested, titrating in increments of 1 to 2 mg as tolerated to induce the required level of sedation. It is anticipated that the usual effective dose would be in the range of 2 to 8 mg. Careful monitoring for respiratory depression is recommended, with a precaution to avoid administration of midazolam to patients with preexisting respiratory compromise, low baseline respiratory rate, or concurrent use of opioid-based medications. Midazolam-related oversedation can be reversed with the benzodiazepine inverse-agonist flumazenil. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this letter. Author Contributions: All the authors made substantial contributions to every aspect of this letter. Sponsor's Role: None.

Door to relocation time for dislocated hip prosthesis: multicentre comparison of emergency department procedural sedation versus theatre-based general anaesthesia

Background:Dislocation of a hip prosthesis is a painful event which has an incidence of 4% for primary total hip arthroplasty. Relocation is traditionally performed under general anaesthesia in the operating...

280: Is Propofol Safe and Effective for Emergency Department Sedation in the Elderly?

To show the efficacy and safety profile of propofol, used for procedural sedation, in patients over the age of 80 in an emergency department setting.

Propofol for ED Procedural Sedation — How Good Is It?

Propofol, an ultra–short-acting sedation agent that might cause hypotension and transient apnea, is becoming increasingly popular for procedural sedation. Canadian researchers prospectively evaluated efficacy, safety, and patient satisfaction in 113 patients (mean age, 50; 62% male) who received propofol for procedural sedation in the emergency department during a 2-year period. The procedures included orthopedic reductions (44%), cardioversion (37%), and abscess incision and drainage …

121: Sedation after Intubation Using Etomidate and a Long-Acting Neuromuscular Blocker

Etomidate is an imidazole hypnotic which is commonly utilized by emergency medicine physicians during rapid sequence intubation. Etomidate’s duration of action is significantly shorter than that of commonly used long-acting paralytic medications (3-12 minutes vs. 25-73 minutes). If additional sedative medications are not administered prior to the conclusion of etomidate’s duration of action, patients are at risk of experiencing paralysis without adequate sedation. The objective of this study was to evaluate the frequency of the administration of additional sedation in pediatric emergency department (ED) patients undergoing endotracheal intubation with etomidate and a long-acting paralytic agent.

Ketamine disposition in children presenting for procedural sedation and analgesia in a children's emergency department

Background: The aim of this study was to describe ketamine pharmacokinetics in children to simulate time-concentration profiles to predict duration of concentrations associated with anesthesia, arousal and analgesia.