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

Procedural sedation in the emergency department by Dutch emergency physicians: a prospective multicentre observational study of 1711 adults

Objective

To describe our experience performing ED procedural sedation in a country where emergency medicine (EM) is a relatively new specialty.

Methods

This is a prospective observational study of adult patients undergoing procedural sedation by emergency physicians (EPs) or EM residents in eight hospitals in the Netherlands. Data were collected on a standardised form, including patient characteristics, sedative and analgesic used, procedural success, adverse events (classified according to World SIVA) and rescue interventions.

Results

1711 adult cases were included from 2006 to 2013. Propofol, midazolam and esketamine (S+ enantiomer of ketamine) were the most used sedatives (63%, 29% and 8%). We had adverse event data on all patients. The overall adverse event rate was 11%, mostly hypoxia or apnoea. There was no difference in adverse event rate between EPs and EM residents. However, there was a significantly higher success rate of the procedure when EPs did the procedural sedation (92% vs 84%). No moderate (unplanned hospital admission or escalation of care) or sentinel SIVA outcomes occurred (pulmonary aspiration syndrome, death or permanent neurological deficit).

Conclusion

Adverse events during procedural sedation occurred in 11% of patients. There were no moderate or sentinel outcomes. All events could be managed by the sedating physician. In a country where EM is a relatively new specialty, procedural sedation appears to be safe when performed by EPs or trained EM residents and has comparable adverse event rates to international studies.

Incidence of Adverse Events in Adults Undergoing Procedural Sedation in the Emergency Department: A Systematic Review and Meta-analysis

OBJECTIVES

This was a systematic review and meta-analysis to evaluate the incidence of adverse events in adults undergoing procedural sedation in the emergency department (ED).

METHODS

Eight electronic databases were searched, including MEDLINE, EMBASE, EBSCO, CINAHL, CENTRAL, Cochrane Database of Systematic Reviews, Web of Science, and Scopus, from January 2005 through 2015. Randomized controlled trials and observational studies of adults undergoing procedural sedation in the ED that reported a priori selected outcomes and adverse events were included. Meta-analysis was performed using a random-effects model and reported as incidence rates with 95% confidence intervals (CIs).

RESULTS

The search yielded 2,046 titles for review. Fifty-five articles were eligible, including 9,652 procedural sedations. The most common adverse event was hypoxia, with an incidence of 40.2 per 1,000 sedations (95% CI = 32.5 to 47.9), followed by vomiting with 16.4 per 1,000 sedations (95% CI = 9.7 to 23.0) and hypotension with 15.2 per 1,000 sedations (95% CI = 10.7 to 19.7). Severe adverse events requiring emergent medical intervention were rare, with one case of aspiration in 2,370 sedations (1.2 per 1,000), one case of laryngospasm in 883 sedations (4.2 per 1,000), and two intubations in 3,636 sedations (1.6 per 1,000). The incidence of agitation and vomiting were higher with ketamine (164.1 per 1,000 and 170.0 per 1,000, respectively). Apnea was more frequent with midazolam (51.4 per 1,000), and hypoxia was less frequent in patients who received ketamine/propofol compared to other combinations. The case of laryngospasm was in a patient who received ketamine, and the aspiration and intubations were in patients who received propofol. When propofol and ketamine are combined, the incidences of agitation, apnea, hypoxia, bradycardia, hypotension, and vomiting were lower compared to each medication separately.

CONCLUSIONS

Serious adverse events during procedural sedation like laryngospasm, aspiration, and intubation are exceedingly rare. Quantitative risk estimates are provided to facilitate shared decision-making, risk communication, and informed consent.

Emergency Procedural Sedation With Propofol in Older Teenagers: Any Cause for Concern?

INTRODUCTION

Propofol is a standard for adult emergency department procedural sedation (EDPS). Use in pediatric patients remains controversial. Our primary objective was to investigate whether adverse events occurred more frequently in teenage pediatric patients receiving propofol for EDPS.

METHODS

This retrospective study examines records from the Halifax Procedural Sedation Registry, collected between January 1, 2006 and May 31, 2013. Patients undergoing EDPS using propofol were divided into those aged 16 to 19 years (teenagers), 20 to 65 years (adults), and older than 65 years (seniors). The primary outcomes were the incidences of hypotension and hypoxia.

RESULTS

Four thousand sixty-three EDPSs were included in the analysis, of which 230 involved teenagers, 2853 adults (mean age, 43.0 years), and 980 seniors (mean age, 77.1). The teenage group was significantly less likely to develop hypotension or hypoxia. These differences were confirmed on multivariate analysis. Patients in the teenage group received higher doses of propofol per kilogram/minute than the other groups. No other differences met statistical significance.

CONCLUSIONS

Teenage patients receiving EDPS with propofol had a lower incidence of adverse events, and both received and tolerated larger adjusted doses of medication than older patients. Satisfaction and duration of EDPS were similar. Concerns about propofol use in younger patients have not been supported by this study. We believe that these findings support the use of propofol for EDPS in older teenagers.