Our large series of propofol sedations performed by emergency physicians supports the safety of this practice. The sentinel adverse event rate of 1% that we identify prompts review: we will in future emphasize adherence to the reduced 0.5 mg kg(-1) propofol dose in the elderly, and reconsider our use of metaraminol. We believe that our application of the World SIVA adverse event tool sets a benchmark for further studies.

The 'Pain Passport' is a novel method of improving the management of pain in children. It consists of a leaflet carried by the patient which records serial pain scores. It attempts to empower patients and prompt medical and nursing staff to evaluate the child's pain. Preliminary audit data in support of this concept are encouraging.

were available on 1766 patients (999 and 767 patients in phases 1 and 3, respectively). The majority of the procedures were colonoscopies, upper gastrointestinal endoscopies, examinations under anesthesia, endoscopic retrograde cholangiopancreatographies, and central venous catheter placements. There was no difference in demographics between the 2 groups. The RSS was inversely associated with the BIS value r = 0.16 (95% confidence interval, −0.19 to −0.12). An RSS of 2 to 3 was maintained in 94% of patients in phase 1 and 96% of patients in phase 3. The mean BIS values were 80.9 (SD, 6.8) in phase 1 and 80.4 (SD, 6.5) in phase 3.The number of sedation-related adverse events was lower in the sample when BIS was used, with an odds ratio of 0.41 (95% confidence interval, 0.28-0.62), and patients with restlessness had a lower BIS value than those without. No serious adverse events or deaths were reported. Moderate sedation administered by nurses using midazolam and fentanyl was usually related to appropriate levels of sedation, as assessed by both the RSS and BIS with a low overall incidence of adverse events. The use of BIS did not change the mean level of sedation, although the number of sedation-related adverse events seems to be lower when BIS was used. COMMENTThese investigators from Duke University Medical Center found that sedation provided by trained nurses was generally associated with appropriate levels of sedation (moderate sedation), as reflected by RSS and BIS values. Use of BIS monitoring to guide anesthetic drug administration did not appreciably change sedation levels. Moreover, the investigators identified that RSS and BIS had a statistically significant inverse correlation, suggesting that BIS is a reliable monitor for assessing sedation for moderate sedation with midazolam, fentanyl, and hydromorphone. Although there were fewer adverse events when BIS values were made visible to sedation nurses, the overall incidence of adverse events was too low to establish a relationship. This is an important and germane study, given that the use of intravenous sedation by nonanesthesia providers has grown enormously, largely as a result of the explosive growth in out-ofoperating room invasive diagnostic and therapeutic procedures. Midazolam-opioid sedation was administered, because propofol was not permitted to be given by nurses at Duke during the time of the study. The cases included gastrointestinal endoscopies, bronchoscopies, examinations under sedation, and central line placement. The goal was to provide moderate, rather than deep, sedation, because in the hands of nonanesthesiologists, deep sedation and moderate sedation are associated with notably different levels of risk. Importantly, no supplemental oxygen was administered. The cases were brief, and the nurses were well trained. There were insufficient numbers of adverse events to identify any important advantage of BIS monitoring. Forty-five of the 999 patients developed hypoxemia, but only 3 of these patients became apneic. As underscored in an acco...

Colonoscopy is a generally safe test whose use is rapidly increasing; complications are unusual and the accepted rate of perforation after diagnostic colonoscopy is between 1 in 800-1500 cases. Colonoscopic perforation may not be recognised at the time and the patient may present to a variety of medical practitioners after discharge from hospital. The presentation is usually with abdominal pain. We report an unusual presentation of colonoscopic perforation in which the patient attended the Emergency Department complaining of a painful neck.