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

Abstract

ObjectiveTo describe our experience performing ED procedural sedation in a country where emergency medicine (EM) is a relatively new specialty.MethodsThis 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.Results1711 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).ConclusionAdverse 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.

A mini‐review of procedural sedation and analgesia in the emergency department

“…15,[19][20][21][22] In Japan, thiopental, propofol, and midazolam are often used as sedatives for PSA, but thiopental is not commonly used for PSA in North America and Europe, thus it is rarely included in the guidelines for PSA in the ED. 2,4,5 Thiopental has some benefits for PSA such as rapid onset and offset when used as a single dose. However, thiopental also has disadvantages for PSA.…”

“…Over the past decade, a number of studies have shown PSA to be safely performed in the ED. [1][2][3][4][5] The availability of ultra-short-acting sedatives and analgesics as well as noninvasive monitoring devices such as capnography have made PSA practice even safer. The availability and common use of sedative and analgesic agents differ depending on region or country.…”

“…2,10 Second, indications for PSA in the ED are different (Table 1). 2,4,5 Third, emergency physician (EP) training opportunities for PSA in Japan are somewhat limited. 11 The Japanese Procedural Sedation and Analgesia Registry (JPSTAR), a multicenter prospective observational study, showed slightly higher incidence of adverse events (AEs) during PSA in participating EDs in Japan than previous studies in other countries.…”

A New Index of Coordinated Posterior and Anterior Evoked EEG to Detect Recall Under Sedation – A Pilot Study

“…Alternatively, sedation often involves greater prevalence of recall as defined by the nature of the targeted clinical condition 13,16,17 . The impact of recall under sedation (RUS) is usually not distressing as patients are expecting some degree of awareness and are not paralyzed, hence, they can signal when becoming aware and/or uncomfortable 13,18–22 .…”

“…Thus, our main study question was whether the P/A index would tend to be different between sedated patients who have recall (as identified by Brice questionnaire 34 – see below) and sedated patients who do not have recall. However, sedation is performed with various drugs and it is known different drugs might have different effect on EEG 35 , on the one hand and different likelihood of recall, on the other hand 16,17,36 . Therefore, despite the pilot nature of this study and its limited sample size and characteristics, we sought ways to evaluate, in a very preliminary manner, whether a possible association between the P/A index and recall might be related to drug type.…”