Procedural sedation and analgesia in a Canadian adult tertiary care emergency department: a case series

Abstract

Objectives:To examine the safety of emergency department (ED) procedural sedation and analgesia (PSA) and the patterns of use of pharmacologic agents at a Canadian adult teaching hospital. Methods: Retrospective analysis of the PSA records of 979 patients, treated between Aug. 1, 2004, and July 31, 2005, with descriptive statistical analysis. This represents an inclusive consecutive case series of all PSAs performed during the study period. Results: Hypotension (systolic blood pressure ≤ 85 mm Hg) was documented during PSA in 13 of 979 patients (1.3%; 95% confidence interval [CI] 0.3%-2.3%), and desaturation (SaO 2 ≤ 90) in 14 of 979 (1.4%; CI 0.1%-2.7%). No cases of aspiration, endotracheal intubation or death were recorded. The most common medication used was fentanyl (94.0% of cases), followed by propofol (61.2%), midazolam (42.5%) and then ketamine (2.7%). The most frequently used 2-medication combinations were propofol and fentanyl (P/F) followed by midazolam and fentanyl (M/F), used with similar frequencies 58.1% (569/979) and 41.0% (401/979) respectively. There was no significant difference in the incidence of hypotension or desaturation between the P/F and M/F treated groups. In these patients, 9.1% (90/979) of patients received more than 2 different drugs. Conclusions: Adverse events during ED PSA are rare and of doubtful clinical significance. Propofol/fentanyl and midazolam/fentanyl are used safely, and at similar frequencies for ED PSA in this tertiary hospital case series. The use of ketamine for adult PSA is unusual in our facility.

Safety and Clinical Effectiveness of Midazolam versus Propofol for Procedural Sedation in the Emergency Department: A Systematic Review

“…1 PS enhances the success rate of these procedures and renders them more humane by providing anxiolysis, sedation, amnesia, and analgesia. The ideal sedative agent for PS has a rapid onset of action and a limited duration of action, can be combined with a short-acting narcotic, and is associated with few major adverse events (AEs).…”

“…The ideal sedative agent for PS has a rapid onset of action and a limited duration of action, can be combined with a short-acting narcotic, and is associated with few major adverse events (AEs). 1,2 Several sedative agents are currently used for PS in adults. 1 At present, the choice of agent depends largely on local practice patterns and practitioner comfort.…”

“…1,2 Several sedative agents are currently used for PS in adults. 1 At present, the choice of agent depends largely on local practice patterns and practitioner comfort. 1,3,4 Registry data from the United States and Canada indicate that propofol is used in 25% to 84% of PS episodes, 1,3,4 and midazolam in 15% to 42%.…”

Emergency department procedural sedation for primary electrical cardioversion — a comparison with procedural sedations for other reasons

“…The Halifax EDPS registry has been previously described but in short all EDPS are prospectively captured and for this study the period of review was June 2006 to September 2014. [11][12][13] The data are inputted by an administrative assistant, and one of the co-authors regularly runs database queries to detect input errors and missing data for the purpose of reconciliation. All data were abstracted from the registry, a Microsoft Access database created specifically for the purpose of managing the quality of EDPS.…”

“…[11] The EDPS program follows a very stringent protocol [12] and the clinical details of every EDPS are recorded on a specific patient care record ( Figure 1). The physician responsible for the patient determines whether they can tolerate the procedure.…”