Safety assessment of high-dose narcotic analgesia for emergency department procedures

Requirement for Discharge in the Care of a Responsible Adult in Procedural Sedation in the Emergency Department: Necessity or Potential Barrier to Health Equity?

BACKGROUND

Procedural sedation is commonly practiced by emergency physicians to facilitate patient care in the emergency department (ED). Although various guidelines have modernized our approach to procedural sedation, many procedural sedation guidelines and practices still often require that patients be discharged into the care of a responsible adult.

DISCUSSION

Such requirement for discharge often cannot be met by underserved and undomiciled patients. Benzodiazepines, opioids, propofol, ketamine, "ketofol," etomidate, and methohexital have all been utilized for procedural sedation in the ED. For patients who may require discharge without the presence of an accompanying responsible adult, ketamine, propofol, methohexital, "ketofol," and etomidate are ideal agents for procedural sedation given rapid onsets, short durations of action, and rapid recovery times in patients without renal or hepatic impairment. Proper pre- and postprocedure protocols should be utilized when performing procedural sedation to ensure patient safety. Through the use of appropriate medications and observation protocols, patients can safely be discharged 2 to 4 h postprocedure.

CONCLUSION

There is no pharmacodynamic or pharmacokinetic basis to require discharge in the care of a responsible adult after procedural sedation. Thoughtful medication selection and the use of evidence-based pre- and postprocedure protocols in the ED can help circumvent this requirement, which likely disproportionally impacts patients who are of low socioeconomic status or undomiciled.

Effectiveness of Sedoanalgesia in Percutaneous Liver Biopsy Premedication

Aim:

Percutaneous needle liver biopsy (PLB) is frequently associated with pain and anxiety. This may discourage the patients for biopsy, and rebiopsies, if needed. We planned a study to investigate the efficacy of additional analgesia or sedation for PLB.

Materials and methods:

The study has been designed as a single-center, prospective study. The PLB was planned for 18- to 65-year-old consecutive patients who were included in the study. The patients were divided into three premedication groups as control, Meperidine, and Midazolam. Hospital Anxiety and Depression Scale (HADS) was used to measure each subject’s anxiety level. Fifteen minutes before the biopsy, 1 mL 0.9% NaCl subcutaneously (sc), 1 mg/kg (max 100 mg) Meperidine sc, or 0.1 mg/kg (max 5 mg) Midazolam intravenously was administered to patients respectively. Then PLB was done with 16 G Menghini needle. The day after, the patients were asked about feelings regarding biopsy.

Results:

Groups were similar by gender and age. The HADS scores prior to PLB and on visual analog scale (VAS, 1-10 points) score during PLB were similar. In the three groups, 7, 12, and 7 patients, respectively, experienced no pain. Other patients explained pain as mild or moderate or severe. The number of patients who agreed for possible rebiopsy was higher in Meperidine and Midazolam groups than in the control group.

Conclusion:

Premedication with Meperidine or Midazolam in PLB would improve patients’ tolerance, comfort, and attitude against a possible repeat PLB.

How to cite this article: Sezgin O, Yaras S, Ates F, Altintas E, Saritas B. Effectiveness of Sedoanalgesia in Percutaneous Liver Biopsy Premedication. Euroasian J Hepato-Gastroenterol 2017;7(2):146-149.

The effect of oral and subcutaneous meperidine on the maximal electroshock seizure (MES) in mice

The likely effect of oral and subcutaneous meperidine on maximal electroshock seizure (MES) in mice was studied. Convulsive current fifty (CC50) was assessed to be 46m A, an electrical pulse causing seizure in 50% of test animals. Doses of 15, 30, 60, or 120 mg/kg meperidine given orally or subcutaneously increased the convulsion threshold of MES as evidenced by a significant dose-dependent reduction of MES below control value (p < .05). An initial hyperactivity reaction that was worsened by noisy and tactile stimuli and tail erection followed by sedation was observed after s.c. injection of 60 or 120 mg/kg meperidine. No significant difference was found between meperidine-induced reductions of control MES values obtained one and two hours after oral doses; the depressed MES values obtained one hour after oral administration of meperidine were significantly different and more powerful than those obtained two hours after s.c. drug administrations (p < .05). Combining previous literature information with the present results, we conclude that such an effect of meperidine can be attributed to cerebellar stimulation.

Nurse-initiated intravenous morphine in the emergency department: efficacy, rate of adverse events and impact on time to analgesia

OBJECTIVES

The objectives of this study were: (i) to measure the analgesic efficacy and frequency of adverse events following autonomous nurse-initiated intravenous morphine in patients presenting with acute pain, awaiting medical assessment; and (ii) to determine whether such a process would improve the time to analgesia.

METHODS

A prospective convenience sample of patients presenting in acute pain received titrated intravenous morphine by experienced emergency nurses. Pain scores on a 10.0 cm visual analogue scale and predetermined adverse events defined by physiological parameters were measured at regular intervals over the following 60 min. Demographic, diagnostic and waiting time data were also recorded.

RESULTS

Three hundred and forty nine patients were enrolled over a 12-month period. The median initial pain score was 8.5 cm, with a reduction to 4.0 cm at 1 h. Respiratory rate, oxygen saturation, heart rate and blood pressure all showed small but statistically significant reductions over 60 min. There were 15 predefined adverse events, 10 episodes of hypotension and five episodes of oxygen desaturation. No intervention other than supplemental oxygen was required. There were no episodes of bradycardia, bradypnoea or reduced level of consciousness. The median time to narcotic was 18 min and the median time to be seen by a doctor was 52 min.

CONCLUSION

Experienced emergency nurses can initiate effective intravenous narcotic analgesia for patients in acute pain awaiting medical assessment, with minimal change in physiological parameters. This process can improve the time to analgesia for patients in acute pain.

Systemic analgesia and sedation in managing orthopedic emergencies

Many potent agents have become available in the emergency department for providing systemic analgesia and sedation for painful orthopedic procedures. This article details the pharmacology and principles of systemic analgesia and sedation, which will help the emergency physician provide maximal patient comfort with minimal complications during painful procedures. The use of an appropriate agent in these situations will optimize the outcome of the procedure itself and result in greater patient satisfaction.

One-week survey of pain intensity on admission to and discharge from the emergency department: a pilot study

The purpose of this pilot study was to determine the incidence and severity of pain intensity in patients 4 years of age and older presenting to the noncritical ward of the emergency department (ED). All patients presenting to the ED of two university hospitals (one general, one pediatric) who were triaged to the noncritical ward during 12 h/day for 1 week were asked to report their pain intensity on admission and again asked just prior to discharge home. The chromatic analogue scale with a range of 0-10 was used as the measure of pain intensity. Pain reports were obtained from half of all patients (58% of adults, 47% of children) admitted during the study week. Approximately one-third (29% of adults and 31% of children) reported no pain on admission, but half of both age groups (52% of adults, 48% of children) reported pain 4/10 or higher. On discharge, one-third of both groups reported pain 4/10 or higher. Eleven percent of both adults and children reported pain 1.5/10 or higher on discharge than on admission. Adult patients with musculoskeletal complaints had the highest pain intensities (mean score admission-discharge, 5.6-4.7/10; other categories, <5). For children, neurological complaints, exclusively headaches, were highest (mean score admission-discharge, 4.8-5.2/10; other categories, <5). Children accompanied by their mothers alone had poorer pain improvement (no change) than children accompanied by their fathers alone or both parents (score improvement of 1). It thus appears that pain is a problem for the majority of patients presenting to the ED. An important percentage of patients leave the ED with more pain than when they arrived. Further investigation is warranted to determine factors predicting poor pain resolution during an ED visit.

Pearls, pitfalls, and updates for pain management

Pain management is one of the most challenging areas we encounter as emergency physicians. However, many of us fail to adequately meet this challenge. This article discusses frequently encountered pain syndromes and pain management options.

A prospective evaluation of the safety and efficacy of methohexital in the emergency department

A prospective observational study in an inner-city teaching hospital was conducted to evaluate the safety and efficacy of intravenous methohexital (MTX) in the emergency department (ED). Pulse oximetry, vital signs and Glasgow Coma Scale (GCS) scores were recorded serially for 30 minutes after the administration of MTX to 76 adult patients. Likert scales of 1 to 5 were used to record the physician's assessment of the adequacy of sedation and the patient's assessments of recall and pain of the procedure. Patients received an average of 88 +/- 21 mg of MTX for a variety of indications (orthopedic procedures, 78%; sedation for other procedures, 14%; intubation, 5%; and psychiatric interview, 3%). No patient had clinically significant changes in heart rate or blood pressure. Eight (10.5%) had apnea, although only one patient had oxygen saturations of less than 90%. Each episode was brief and easily managed with bag-valve-mask ventilation. Risk factors for apnea included a history of alcoholism (P = .0003) and recent recreational narcotic use (P = .0139). Patients were maximally sedated in an average of 37 +/- 42 seconds. In the subset of initially alert patients, GCS scores decreased from 15 at baseline to 5.9 +/- 4.5. The physician's assessment of the adequacy of sedation was excellent (4.7 +/- 0.7). Patients reported little recall (1.3 +/- 0.9) or pain (1.3 +/- 0.8). It was concluded that MTX caused clinically insignificant changes in hemodynamics or oxygenation, although respiratory depression did occur; significant respiratory depression was brief and easily managed. MTX provided rapid and excellent levels of sedation with little or no patient recall or pain.