Procedural Sedation Cage Match

It's a typical busy post-Thanksgiving shift in the ED.  It seems like patients with acute decompensated heart failure, sepsis, NSTEMI's and a whole host of other ailments are tucked in every corner and crevice of the ED.  Just as you finish putting in orders on the last patient you saw, your next patient rolls by on an EMS stretcher.  You see from your computer that the patient is on a backboard and in a c-collar after what clearly was some form of traumatic event.  He's screaming in pain and holding his left leg flexed at the hip and internally rotated.  

By Hellerhoff (Own work) [CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

"Jeez, I bet that hip is dislocated," you say to yourself.  You talk with the patient, briefly examine him and put in orders for pain medications and x-rays.  You complete your exam fortunately not finding any other signs of significant trauma and walk over to the radiology tech room to get an early peak at the film as it's being developed.

Now what?  You know you're going to need to reduce this dislocation, to not do so would risk avascular necrosis.  Tammy, one of the nurses you are working with that day is already 2 steps ahead of you.  "Doc, we're getting everything set up for the sedation, you're going to need for that hip that's out. What drugs do you want us to pull up?"

You ponder the possibilities.  Versed and fentanyl would probably work, but always seems to take forever.  Etomidate is fast for sure but you get twitchy just thinking about that last patient who had myoclonus with it.  Propofol is a newer drug to your department and has seemed to work well.  But then you also wonder whether ketamine might do the trick?  What about ketafol - ketamine and propofol? Is there one agent that's better then the rest?  Is any one agent really superior?

---

Articles We Covered in Journal Club and the Podcast

• Miner, J. R., Gray, R. O., Bahr, J., Patel, R., & McGill, J. W. (2010). Randomized Clinical Trial of Propofol Versus Ketamine for Procedural Sedation in the Emergency Department. Academic Emergency Medicine, 17(6), 604–611. doi:10.1111/j.1553-2712.2010.00776.x 
• Miner, J. R., Danahy, M., Moch, A., & Biros, M. (2007). Randomized Clinical Trial of Etomidate Versus Propofol for Procedural Sedation in the Emergency Department. Annals of Emergency Medicine, 49(1), 15–22. doi:10.1016/j.annemergmed.2006.06.042
• David, H., & Shipp, J. (2011). A Randomized Controlled Trial of Ketamine/Propofol VersusPropofol Alone for Emergency Department Procedural Sedation. Annals of Emergency Medicine, 57(5), 435–441. doi:10.1016/j.annemergmed.2010.11.025

• Andolfatto, G., Abu-Laban, R. B., Zed, P. J., Staniforth, S. M., Stackhouse, S., Moadebi, S., & Willman, E. (2012). Ketamine-Propofol Combination (Ketofol) Versus Propofol Alone for Emergency Department Procedural Sedation and Analgesia: A Randomized Double-Blind Trial. Annals of Emergency Medicine, 59(6), 504–512.e2. doi:10.1016/j.annemergmed.2012.01.017

Summary & Highlights of the Discussion

There is no clear evidence of superiority (or even of increased safety) of one sedative agent over any other for procedural sedation in the ED.

These articles all looked at what can be viewed as a surrogate outcome of patient important outcomes.  Though it make pathophysiologic sense, it is unclear whether or not subclinical respiratory depression (rises or falls in EtCO2, modest O2 desaturation, apnea) actually matters in the care of patients.  In our discussion, we felt as if some additional research is needed to primarily pursue outcomes that might by important to both patients and providers (depth of sedation, memory of sedation, patient satisfaction with procedural sedation, patent experience of pain, total time sedated, time of one-on-one nursing, first pass procedural success, etc).

Though no one agent is clearly superior to another, based on the rates of adverse outcomes in the studies and based on provider experience there are likely agents that are better in certain circumstances (also another possible area of research).  In general we felt that propofol portends a slightly higher risk of respiratory depression requiring provider intervention as well as hypotension.  Ketamine may provide a slightly longer duration of sedation and preserves (or even increases) blood pressure.  Etomidate is very quick on and off but the risk of myoclonus makes many providers dislike it for orthopedic procedures.

The biggest takeaway is to use all of these agents as you are developing your practice pattern.  It is best to have as many tools in your toolbox as possible when it comes to patient care.

Let's Start a conversation! 

Do you think one agent is clearly better than another?  Is there a particular medication you prefer in a severe polytrauma? What about for electrical cardioversion?  Chest tubes? Abscess I&D?

Comment below and let us know your thoughts!

---

In-Depth Analysis Sheets

Miner, J. R., Gray, R. O., Bahr, J., Patel, R., & McGill, J. W. (2010). Randomized Clinical Trial of Propofol Versus Ketamine for Procedural Sedation in the Emergency Department. Academic Emergency Medicine, 17(6), 604–611. doi:10.1111/j.1553-2712.2010.00776.x 

Miner, J. R., Danahy, M., Moch, A., & Biros, M. (2007). Randomized Clinical Trial of Etomidate Versus Propofol for Procedural Sedation in the Emergency Department. Annals of Emergency Medicine, 49(1), 15–22. doi:10.1016/j.annemergmed.2006.06.042

David, H., & Shipp, J. (2011). A Randomized Controlled Trial of Ketamine/Propofol VersusPropofol Alone for Emergency Department Procedural Sedation. Annals of Emergency Medicine, 57(5), 435–441. doi:10.1016/j.annemergmed.2010.11.025

---

Thanks to David Strong, MD, PhD, Ben Ostro, MD, and Woods Curry, MD, PGY-3 residents in the University of Cincinnati Dept of EM Residency Training Program for their leadership of the journal club discussion and to the residents and faculty for their vibrant discussion of the topic!