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Barbiturates and benzodiazepines (BZDs) can relieve insomnia and high levels of anxiety. Effects of barbiturates are similar to that of alcohol. Barbiturate use entails risk of addiction, and death from accidental or suicidal overdose. In the 1970s, the safer BZDs became available. Like barbiturates, BZDs facilitate the neural inhibitory action of the neurotransmitter GABA, but are unlikely to produce pleasurable intoxication and are less addictive than barbiturates. BZDs can impair driving and increase the probability of accidental falls, especially when used concurrently with alcohol. Stopping extended intake of BZDs can result in a withdrawal syndrome of anxiety, insomnia, and a general feeling of malaise. Addiction to BZDs occurs most often in individuals with an SUD of another addictive drug. As a secondary drug of abuse, BZDs can potentiate the effects of opioid drugs or alcohol, and relieve the anxiety and agitation of addictive stimulant use. Newer drugs including zolpidem (Ambien), benzodiazepine-receptor agonists with little abuse potential that produce a brief hypnotic effect with little residual sedation the following day, are now most often used to treat insomnia.
Introduction: Lacerations are common in children presenting to the emergency department (ED). They are often uncooperative when sutures are needed and may require procedural sedation. Few studies have evaluated intranasal (IN) ketamine for procedural sedation in children, with doses from 3 to 9 mg/kg used mostly for dental procedures. In a previous dose escalation trial, DosINK-1, 6 mg/kg was found to be the optimal IN ketamine dose for procedural sedation for sutures in children. In this trial, we aim to further evaluate the efficacy of this dose. Methods: We conducted a multicentre single-arm clinical trial. A convenience sample of 30 uncooperative children between 1 and 12 years (10 to 30 kg) with no cardiac or kidney disease, active respiratory infection, prior administration of opioid or sedative agents received 6 mg/kg of IN ketamine using an atomizer for their laceration repair with sutures in the ED. The primary outcome was defined as the proportion (95% CI) of patients who achieved an adequate procedural sedation evaluated with the PERC/PECARN consensus criteria. Results: Thirty patients were recruited from April 2018 to November 2019 in 2 pediatric ED. The median age was 3.2 (interquartile range(IQR), 1.9 to 4.7) years-old with laceration of more than 2 cm in 20 (67%) patients and in the face in 21 (70%) cases. Sedation was effective in 18 out of 30 children 60% (95%CI, 45 to 80), was suboptimal in 6 patients (20%) with a procedure completed with minimal difficulties, and unsuccessful in the remaining 6 (20%), all without serious adverse event. Similarly, 21/30 (70%) physicians were willing to reuse IN ketamine at the same doses and 25 parents (83%) would agree to the same sedation in the future. Median time to return to baseline status was 58 min (IQR, 33 to 73). One patient desaturated during the procedure and required transitory oxygen and repositioning. After the procedure, 1 (3%) patient had headache, 1 (3%) patient had nausea, and 2 (7%) patients vomited. Conclusion: A single dose of 6 mg/kg of IN Ketamine for laceration repair with sutures in uncooperative children is safe and facilitated the procedure in 60% (95%CI, 45 to 80) of patients, was suboptimal in 20% and unsuccessful in 20% of patients. As seen with IV ketamine, an available additional dose of IN ketamine for some children if needed could potentially increase proportion of successful sedation. However, the safety and efficacy of repeated doses needs to be addressed.
Introduction: The Cunningham reduction method for anterior shoulder dislocation offers an atraumatic alternative to traditional reduction techniques without the inconvenience and risk of procedural sedation and analgesia (PSA). Unfortunately, success rates as low as 27% have limited widespread use of this method. Inhaled methoxyflurane (I-MEOF) offers a rapidly administered, minimally invasive option for short-term analgesia. We conducted a pilot study to evaluate the feasibility of studying whether I-MEOF increased success rates for atraumatic reduction of anterior shoulder dislocation. Methods: A convenience sample of 20 patients with uncomplicated anterior shoulder dislocations were offered the Cunningham reduction method supported by methoxyflurane analgesia under the guidance of an advanced care paramedic. Operators were instructed to limit their attempt to the Cunningham method. Outcomes included success rate without the requirement for PSA, time to discharge, and operator and patient satisfaction with the procedure. Results: 20 patients received I-MEOF and an attempt at Cunningham reduction. 80% of patients were male, median age was 38.6 (range 18-71), and 55% were first dislocations of that joint. 35% (8/20 patients) had reduction successfully achieved by the Cunningham method under I-MEOF analgesia. The remainder proceeded to closed reduction under PSA. All patients had eventual successful reduction in the ED. 60% of operators reported good to excellent satisfaction with the process, with inadequate muscle relaxation being identified as the primary cause of failed initial attempts. 80% of patients reported good to excellent satisfaction. Conclusion: Success with the Cunningham technique was marginally increased with the use of I-MEOF, although 65% of patients still required PSA to facilitate reduction. The process was generally met with satisfaction by both providers and patients, suggesting that early administration of analgesia is appreciated. Moreover, one-third of patients had reduction achieved atraumatically without need for further intervention. A larger, randomized study may identify patient characteristics which make this reduction method more likely to be successful.
Psychiatric emergencies are often accompanied by behavioral disturbances that interfere with normal assessment and call for immediate intervention. Different pharmacological treatment regimens have been used for this purpose. Most of these regimens are based upon common clinical practice and have limited evidence base. Recently, a major publication by experts in the field of emergency psychiatry has covered this topic and the therapeutic armamentarium has been extended with the atypical antipsychotics. However, research is still hampered by different methodological limitations: unclear definition of the agitated state and therapeutic goal, idiosyncratic measurement, small sample sizes. The perspective of the patient and the interaction between the emergency care setting and treatment regimen also need further attention. All these important, but often neglected issues are covered in a selective review of the literature.
Since February 2016, French Claeys-Leonetti law has recognized patients' right to confront incurable diseases with short-term prognosis and refractory physical or psychological or existential symptoms by requesting continuous deep sedation until death (CDSUD). Determining when psychological or existential distress is refractory and unbearable remains complex and controversial.
This review provides a comprehensive thought on CDSUD for advanced incurable patients with refractory psychological and/or existential distress in palliative care settings. It offers guidance on psychiatric or psychological diagnosis for explaining patients' requests for CDSUD.
A narrative literature review (2000–2019) was conducted on the MedLine search about the use of palliative sedation in cases of refractory psychological and/or existential distress.
(1) Definitions of “refractory symptom,” “refractory psychological distress,” and “refractory existential distress” are inconsistent; (2) alternative diagnoses might obscure or be obscured by psycho-existential distress; and (3) criteria on meanings, reasons for requests, decision-making processes, and functions are evolving in practice.
Significance of results
Before implementing CDSUD, palliative healthcare professionals should seek input from psycho-oncologists in palliative care. Mental health professionals should analyze and assess the reasons for psychological and/or existential distress, consider the intentionality processes of requests, and explore alternative diagnoses, such as depressive or adjustment disorders, demoralization syndrome, desire to hasten death, and desire for euthanasia. Therapeutic responses (e.g., pharmacological and psychotherapeutic) should be implemented before deciding that psycho-existential distress is refractory.
Introduction: Procedural sedation in the emergency department (ED) for children undergoing painful procedures is common practice, however little is known about sedation in very young children. We examined the effect of young age on sedation outcomes. Methods: This is a secondary analysis of an observational cohort study of children 0-18 years undergoing procedural sedation in six pediatric EDs across Canada. We compared presedation state, indication for sedation, medications, sedation efficacy and four main post-sedation outcomes (serious adverse events (SAE), significant interventions, oxygen desaturation and vomiting) between patients who ≤2 years with those >2 years. Pre-sedation state, medications, indication for sedation and time intervals were summarized using frequency and percentage and compared with chi2 test. Logistic regression was used to examine associations between age group and outcomes. Results: 6295 patients were included; 5349 (85%) were >2 years and 946 (15%) were ≤2 years. Children ≤2 years were sedated most commonly for laceration repair (n = 450; 47.6%), orthopedic reduction (165; 17.4%) and abscess incision and drainage (136; 14.4%). Children >2years were sedated most commonly for orthopedic reductions (3983; 74.5%). Ketamine was the most common medication in both groups, but was used most frequently in children ≤2 years (80.9% vs 58.9%; p < 0.001). There was no difference in the incidence of SAE, significant interventions or oxygen desaturation between age groups, however children ≤2 years were less likely to vomit (Table 1). Young children had decreased odds of a successful sedation (OR 0.48; 95%CI: 0.37 to 0.63). On average, patients ≤2 years were sedated for 7 minutes less (74.1 vs 81.0 p < 0.001) and discharged 10 minutes sooner (90.1 vs 100.8 p < 0.001). Table 1 ≤2 years (n = 946) >2 years (n = 5349) OR (95%CI)* p-value n(%) n(%) Serious Adverse Event 8 (0.85) 59 (1.0) 0.76 (0.43-1.7) 0.477 Significant intervention 10 (1.0) 76 (1.4) 0.74 (0.34-1.4) 0.374 Oxygen Desaturation 50 (5.3) 303 (5.6) 0.93 (0.67-1.3) 0.640 Vomiting 14 (1.5) 314 (5.9) 0.24 0.13-0.41) <0.001 *Reference category: ≤2 years. Conclusion: Children ≤2 years most commonly received ED sedation for laceration repair using ketamine. Young age was not associated with a significant difference in SAEs, significant intervention or desaturation but was associated with decreased odds of vomiting and of successful sedation.
Introduction: Intranasal dexmedetomidine (IND) is an emerging agent for procedural distress in children. However, studies to date have been limited by small samples and imprecise estimates of effect size. We sought to summarize the evidence on the effectiveness of IND for procedures associated with distress in children. Methods: We performed electronic searches of MEDLINE (1946-2018), EMBASE (1980-2018), Google Scholar (2018), CINAHL (1981-2018), Cochrane Central Register of Controlled Trials (2018), 6 clinical trials registries and conference proceedings (2010-2018). Title searches, data abstraction, and risk of bias assessments were performed in duplicate. We included all published and unpublished, randomized and quasi-randomized trials of IND for procedures in children younger than 19 years of age without language restriction. The methodological quality of studies was evaluated using the Cochrane Collaboration's Risk of Bias tool. The primary outcome was the proportion of participants that were deemed to be adequately sedated for the procedure. Results: Of 661 studies, 18 met inclusion criteria. Trials involved 2128 participants, age 1 month - 14 years (836, 39.3% females), who received IND 1 - 4 mcg/kg either by drops (n = 12), atomizer (n = 4), or both (n = 2). 12 trials were eligible for meta-analysis. 13 trials used validated instruments to assess sedation. All studies except one were associated with low or moderate risk of bias. For painful procedures (IV insertion; laceration repair; dental extraction), the pooled OR (95% CI) for adequate sedation and need for additional analgesia was non-significant [1.19 (0.53, 2.65)] and [2.16 (0.62, 7.49)], respectively (n = 5). For non-painful procedures (diagnostic imaging), the corresponding pooled OR (95% CI) favored IND [3.04 (1.58, 5.82)] and [4.44 (2.11, 9.35)], respectively (n = 7). Time to onset and duration of sedation ranged from 13-31 minutes and 41-91.5 minutes, respectively. For adverse effects, the pooled OR (95% CI) was not significantly different between IND and comparators [0.58 (0.22, 1.55] and there were no serious adverse events. Conclusion: IND at doses 1 to 4 mcg/kg are safe and adequately sedate children undergoing non-painful procedures, although the ease of administration must be weighed against the risk of prolonged sedation. Additional trials with larger sample sizes and greater methodologic rigor are needed for painful emergency department procedures such as laceration repair and IV insertion.
Introduction: Endotracheal intubation (ETI) is a lifesaving procedure commonly performed by emergency department (ED) physicians that may lead to patient discomfort or adverse events (e.g., unintended extubation) if sedation is inadequate. No ED-based sedation guidelines currently exist, so individual practice varies widely. This study's objective was to describe the self-reported post-ETI sedation practice of Canadian adult ED physicians. Methods: An anonymous, cross-sectional, web-based survey featuring 7 common ED scenarios requiring ETI was distributed to adult ED physician members of the Canadian Association of Emergency Physicians (CAEP). Scenarios included post-cardiac arrest, hypercapnic and hypoxic respiratory failure, status epilepticus, polytrauma, traumatic brain injury, and toxicology. Participants indicated first and second choice of sedative medication following ETI, as well as bolus vs. infusion administration in each scenario. Data was presented by descriptive statistics. Results: 207 (response rate 16.8%) ED physicians responded to the survey. Emergency medicine training of respondents included CCFP-EM (47.0%), FRCPC (35.8%), and CCFP (13.9%). 51.0% of respondents work primarily in academic/teaching hospitals and 40.4% work in community teaching hospitals. On average, responding physicians report providing care for 4.9 ± 6.8 (mean ± SD) intubated adult patients per month for varying durations (39.2% for 1–2 hours, 27.8% for 2–4 hours, and 22.7% for ≤1 hour). Combining all clinical scenarios, propofol was the most frequently used medication for post-ETI sedation (38.0% of all responses) and was the most frequently used agent except for the post-cardiac arrest, polytrauma, and hypercapnic respiratory failure scenarios. Ketamine was used second most frequently (28.2%), with midazolam being third most common (14.5%). Post-ETI sedation was provided by > 98% of physicians in all situations except the post-cardiac arrest (26.1% indicating no sedation) and toxicology (15.5% indicating no sedation) scenarios. Sedation was provided by infusion in 74.6% of cases and bolus in 25.4%. Conclusion: Significant practice variability with respect to post-ETI sedation exists amongst Canadian emergency physicians. Future quality improvement studies should examine sedation provided in real clinical scenarios with a goal of establishing best sedation practices to improve patient safety and quality of care.
Heavy alcohol use is pervasive and one of our most significant global health burdens. Early theories posited that certain alcohol response phenotypes, notably low sensitivity to alcohol (‘low-level response’) imparts risk for alcohol use disorder (AUD). However, other theories, and newer measures of subjective alcohol responses, have challenged that contention and argued that high sensitivity to some alcohol effects are equally important for AUD risk. This study presents results of a unique longitudinal study in 294 young adult non-dependent drinkers examined with alcohol and placebo testing in the laboratory at initial enrolment and repeated 5 years later, with regular follow-up intervals assessing AUD (trial registration: http://clinicaltrials.gov/ct2/show/NCT00961792). Findings showed that alcohol sedation was negatively correlated with stimulation across the breath alcohol curve and at initial and re-examination testing. A higher rather than lower alcohol response phenotype was predictive of future AUD. The findings underscore a new understanding of factors increasing vulnerability to AUD.
We read with interest the recent editorial, “The Hennepin Ketamine Study,” by Dr. Samuel Stratton commenting on the research ethics, methodology, and the current public controversy surrounding this study.1 As researchers and investigators of this study, we strongly agree that prospective clinical research in the prehospital environment is necessary to advance the science of Emergency Medical Services (EMS) and emergency medicine. We also agree that accomplishing this is challenging as the prehospital environment often encounters patient populations who cannot provide meaningful informed consent due to their emergent conditions. To ensure that fellow emergency medicine researchers understand the facts of our work so they may plan future studies, and to address some of the questions and concerns in Dr. Stratton’s editorial, the lay press, and in social media,2 we would like to call attention to some inaccuracies in Dr. Stratton’s editorial, and to the lay media stories on which it appears to be based.
Ho JD, Cole JB, Klein LR, Olives TD, Driver BE, Moore JC, Nystrom PC, Arens AM, Simpson NS, Hick JL, Chavez RA, Lynch WL, Miner JR. The Hennepin Ketamine Study investigators’ reply. Prehosp Disaster Med. 2019;34(2):111–113
Methoxyflurane is an inhalation analgesic used in the emergency department (ED) but also has minimal sedative properties. The major aim of this study was to evaluate the success rate of methoxyflurane for acute anterior shoulder dislocation (ASD) reduction. The secondary aim was to assess the impact of methoxyflurane on ED patient flow compared to propofol.
A health record review was performed for all patients presenting with ASD who underwent reduction with either methoxyflurane or propofol over a 13-month period (December 2016 – December 2017). The primary outcome was reduction success for methoxyflurane, while secondary outcomes such as recovery time and ED length of stay (LOS) were also assessed compared to propofol. Patients with fracture dislocations, polytrauma, intravenous, or intramuscular opioids in the pre-hospital setting, no sedation for reduction, and alternative techniques of sedation or analgesia for reduction were excluded.
A total of 151 patients presented with ASD during the study period. Eighty-two patients fulfilled our inclusion criteria. Fifty-two patients had ASD reduction with propofol while 30 patients had methoxyflurane. Successful reduction was achieved in 80% (95% CI 65.69% to 94.31%) patients who used methoxyflurane. The median recovery time and ED LOS were 30 minutes [19.3-44] and 70.5 minutes [49.3-105], which was found to be shorter for the methoxyflurane group, who had successful reductions compared to sedation with propofol.
Methoxyflurane was used successfully in 30% of the 82 patients undergoing reduction for ASD, while potentially improving ED efficiency.
The importance of the proper identification of delirium, with its high incidence and adversities in the intensive care setting, has been widely recognized. One common screening instrument is the Intensive Care Delirium Screening Checklist (ICDSC); however, the symptom profile and key features of delirium dependent on the level of sedation have not yet been evaluated.
In this prospective cohort study, the ICDSC was evaluated versus the Diagnostic and Statistical Manual, 4th edition, text revision, diagnosis of delirium set as standard with respect to the symptom profile, and correct identification of delirium. The aim of this study was to identify key features of delirium in the intensive care setting dependent on the Richmond Agitation and Sedation Scale levels of sedation: drowsiness versus alert and calmness.
The 88 delirious patients of 225 were older, had more severe disease, and prolonged hospitalization. Irrespective of the level of sedation, delirium was correctly classified by items related to inattention, disorientation, psychomotor alterations, inappropriate speech or mood, and symptom fluctuation. In the drowsy patients, inattention reached substantial sensitivity and specificity, whereas psychomotor alterations and sleep-wake cycle disturbances were sensitive lacked specificity. The positive prediction was substantial across items, whereas the negative prediction was only moderate. In the alert and calm patient, the sensitivities were substantial for psychomotor alterations, sleep-wake cycle disturbances, and symptom fluctuations; however, these fluctuations were not specific. The positive prediction was moderate and the negative prediction substantial. Between the nondelirious drowsy and alert, the symptom profile was similar; however, drowsiness was associated with alterations in consciousness.
Significance of results
In the clinical routine, irrespective of the level of sedation, delirium was characterized by the ICDSC items for inattention, disorientation, psychomotor alterations, inappropriate speech or mood and symptom fluctuation. Further, drowsiness caused altered levels of consciousness.
At the QEII Health Sciences Centre Emergency Department (ED) in Halifax, Nova Scotia, advanced care paramedics (ACPs) perform procedural sedation and analgesia (PSA) for many indications, including orthopedic procedures. We have begun using ACPs as sedationists for emergent upper gastrointestinal (UGI) endoscopy. This study compares ACP-performed ED PSA for UGI endoscopy and orthopedic procedures in terms of adverse events, airway intervention, vasopressor requirement, and PSA medication use.
A data set was built from an ED PSA quality control database matching 61 UGI endoscopy PSAs to 183 orthopedic PSAs by propensity scores calculated using age, gender, and the American Society of Anesthesiologists (ASA) classification. Outcomes assessed were hypotension (systolic BP<100 mm Hg or a 15% decrease from baseline), hypoxia (SaO2<90%), apnea (>30 sec), vomiting, arrhythmias, death, airway intervention, vasopressor requirement, and PSA medication use.
UGI endoscopy patients experienced hypotension more frequently than orthopedic patients (OR=4.11, CI: 2.05-8.22) and required airway repositioning less often (OR=0.24, CI: 0.10-0.59). They received ketamine more frequently (OR=15.7, CI: 4.75-67.7) and fentanyl less often (OR=0.30, CI: 0.15-0.63) than orthopedic patients. Four endoscopy patients received phenylephrine, and one required intubation. No patient died in either group.
In ACP-led sedation for UGI endoscopy and orthopedic procedures, adverse events were rare with the notable exception of hypotension, which was more frequent in the endoscopy group. Only endoscopy patients required vasopressor treatment and intubation. We provide preliminary evidence that ACPs can manage ED PSA for emergent UGI endoscopy, although priorities must shift from pain control to hemodynamic optimization.
Introduction: Emergency department (ED) physicians strive to provide analgesia, amnesia and sedation for patients undergoing painful procedures through the use of procedural sedation (PS). While, PS is generally safe and effective in the ED, there is institutional variability and clinician disagreement with respect to the bedside equipment required for airway management and the monitoring of adverse events. The primary goal of this research project was to describe the variability of the bedside setup utilized by Canadian ED physicians preforming PS in conjunction with self-reported adverse events. Methods: An electronic survey was distributed through the Canadian Association of Emergency Physicians (CAEP). Practicing physician members of CAEP were invited to complete the survey. The 20 question survey encompassed various aspects of PS including physician choices regarding bedside setup of airway equipment, and prevalence of self-reported adverse events. The primary outcome was the quantification of variability among ED physicians with respect to the above listed aspects of PS. Data was presented with simple descriptive statistics. Results: 278 ED physicians responded to our survey (response rate 20.9%). Respondents were primarily academic (53.2%) or community hospital based (38.2%). With emergency medicine training as: CCFP-EM (55.2%), FRCPC (30.1%), and CCFP (9.0%). The ED area in which PS was carried out varied; bedside (30.5%), procedure room (37.1%), resuscitation area (31.2%). The basic equipment set utilized appears to be a bag valve mask, suction, and an oral airway. These 3 items were present 95.4%, 95.9%, and 86.3% of the time respectively. The preparation of other items such as capnography and difficult airway equipment is highly variable and appears to be physician specific rather than clinical situation specific. The most common physician self-reported adverse events associated with PS appear to be hypoxia (Spo2<90%), hypotension (sBP<90), and prolonged sedation which occurred in 10.7%, 8.3%, and 8.1% of PS performed. Conclusion: There appears to be significant practice variability with respect to the clinical setting as well as the equipment ED physicians prefer when administering PS. Given that causal relationships cannot be inferred between airway/monitoring equipment preferences and adverse events, future studies should be targeted at identifying optimal bedside set ups which minimize adverse events.
Introduction: Laceration is common in children presenting to the emergency department (ED). They are often uncooperative related to pain and distressed during repair. Currently, there are wide variations regarding sedation and analgesia practices when sutures are required. There is a growing interest in the intranasal (IN) route for procedural sedation and pain control because of its effectiveness potential and ease of administration. Few studies have evaluated IN ketamine for procedural sedation in children with reported doses ranging from 3 to 9 mg/kg. The objective is to evaluate the optimal IN ketamine dose for effective and safe procedural sedation for laceration repair in children aged 1 to 12 years. Methods: A dose escalation clinical trial with an initial dose of 3 mg/kg of IN ketamine up to a maximum dose of 9 mg/kg in children 1 to 12 years old, using a 3+3 trial design. For each tested dose, 3 patients are enrolled. Escalation to the next dose is permitted if sedation is unsuccessful in at least one patient without serious adverse event (SAE). Regression to prior dose is warranted in the occurrence of two or more SEAs. This process is repeated until effective sedation for 6 patients at two consecutive doses is achieved with a maximum of 1 SAE or if regression occurs. The primary outcome is the optimal dose for successful procedural sedation as per the PERC/PECARN consensus criteria. Secondary outcome, namely, pain and anxiety levels, parent, patient and provider satisfaction, recovery time, length of stay in the ED, side effects and adverse event are recorded. Results: Nine patients have been recruited from March to December 2017 with median age of 2.9 years-old and with laceration length of 2 to 5 cm and with facial involvement in 55% of cases, respectively. Sedation was successful in 1/3, 1/3 and 3/3 of patients at doses of 3, 4, 5 mg/kg respectively, without any SAE. Median time from ketamine administration to return to baseline status and discharge were 35 and 98 min, respectively. We expect to complete patient recruitment in March 2018. Conclusion: The results from our trial is a groundwork for future dose-finding study. Pending study completion, a multicentric dose validation trial, is set up to further validate the optimal dose from dosINK1 trial. IN ketamine has the potential to improve the field of procedural sedation for children by introducing an effective IN agent with respiratory stability but without the need for an IV line insertion not otherwise needed.
Introduction: Emergency department (ED) physicians strive to provide analgesia, amnesia and sedation for patients when performing painful procedures through the use of procedural sedation (PS). Examination of the literature suggests that the application of PS appears to be variable with institutional influences and clinician disagreement on pharmacology, airway management, and monitoring. The primary goal of this research project was to describe the variability of practice with respect to pharmacologic choices and clinical applications of PS among Canadian ED physicians. Methods: An electronic survey was distributed through the Canadian Association of Emergency Physicians (CAEP). Practicing physician members of CAEP were invited to complete the survey. The 20 question survey encompassed various aspects of PS including physician choices regarding PS indications and pharmacology. The primary outcome was the quantification of practice variability among ED physicians with respect to the above listed aspects of PS. The data was presented with simple descriptive statistics. Results: To date, 278 ED physicians responded to our survey (response rate 20.3%). Respondents were primarily academic hospital (53.2%) or community hospital based (38.2%). With emergency medicine training as: CCFP-EM (55.2%), FRCPC (30.1%), and CCFP (9.0%). There was relative agreement on the following interventions requiring PS: 98.4% applied PS for electrical cardioversion and 98.1% for brief (<10 mins) orthopedic manipulations. However, only 36.3% utilized PS for burn debridement in the ED. PS was utilized less frequently (78.1%) for prolonged (>10mins) orthopedic manipulations than brief manipulations. For all procedures aggregated, in hemodynamically stable patients with an American Society of Anesthesiology (ASA) score of 1, ED physicians utilized propofol 76.3% of the time. Additional agents were utilized at the following rates: fentanyl-propofol (7.6%), ketamine (7.6%), and fentanyl (4%). This inclination towards propofol alone appears to be consistent across modality of ER training, type of ER setting (rural vs academic), and volume of PS performed. Conclusion: This study demonstrates that Canadian ED physicians have a clear preference for propofol as a first line pharmacologic agent when administering PS in hemodynamically stable, ASA1 patients. Conversely, there appears to be more variation amongst ED physicians with respect to second line pharmaceutical choices for PS.
Background: Intraoperative sedation is often used to facilitate deep brain stimulation (DBS) surgery; however, these sedative agents also suppress microelectrode recordings (MER). To date, there have been no studies that have examined the effects of differing sedatives on surgical outcomes and the success of DBS surgery. Methods: We performed a retrospective study to evaluate the effect of differing sedative agents on postoperative surgical outcomes at 6 months in parkinsonian adult patients who underwent DBS surgery, from January 2004 through December 2014, at one academic center. Surgical outcomes of DBS were evaluated using a simplified Unified Parkinson Diseases Rating Score-III and levodopa dose equivalent reduction at baseline and 6 months postoperatively. Results: We analyzed data from 121 of 124 consecutive parkinsonian patients. Propofol, dexmedetomidine, remifentanil, and midazolam were used individually or in combination. All sedatives were routinely discontinued 20 to 30 minutes before MER, in accordance with our institutional protocol. We found no statistically significant association between the use of individual agent or combination of sedative agents and surgical outcomes at 6 months, the success of DBS, duration of MER, duration of stage 1 procedure, and perioperative complications. Conclusions: Our study showed that the choice of sedative agent was not associated with poor surgical outcomes after DBS surgery using MER and macrostimulation techniques in parkinsonian patients.
In order to fully participate in informed consent, patients must understand what it is that they are agreeing, or not agreeing, to. In most cases, patients look to their clinicians to help develop the appropriate understanding required to give informed consent. Often the quality of the information available as well as the delivery methods are not optimal.
Using a visual aid as an adjunct to risk communication in a stressful setting as the Emergency Department has a clear potential in facilitating the communication process. To support more accurate and consistent presentation of risk, we formed a team with implementation scientists, patient education specialists, nurses, physicians, and professional designers to transform the information available into a 6th grade reading level visual aid tool. We applied a DMAIC (Define, Measure, Analyze, Improve and Control) process to design the tool. We measured and analyzed its effectiveness through feedback from providers, patients, and caregivers. This cycle happened 3 times until we reached the final version of the visual aid.
We utilized a DMAIC methodology as well as modified Delphi method to create and refine a visual aid tool. Several rounds of end-user feedback along with DMAIC allowed us to create a tool that was consistently better with each round of development, analysis and feedback. After arriving at the final version of the tool, we surveyed physicians in our Emergency Department. We measured the difficulty to understand the information, whether doctors think the visual aid will help patients to understand the data, and the appropriateness of the tool’s length and the amount of information in it.
We believe that our experience can be replicated by other researchers and clinicians in the endeavor of translating the evidence into clinical practice. An effort should be made to fully translate research findings until the end of the research to practice continuum in order to better translate knowledge into a useful and useable form for informed consent decisions in busy clinical practice.
Although procedural sedation for cardioversion is a common event in emergency departments (EDs), there is limited evidence surrounding medication choices. We sought to evaluate geographic and temporal variation in sedative choice at multiple Canadian sites, and to estimate the risk of adverse events due to sedative choice.
This is a secondary analysis of one health records review, the Recent Onset Atrial Fibrillation or Flutter-0 (RAFF-0 [n=420, 2008]) and one prospective cohort study, the Recent Onset Atrial Fibrillation or Flutter-1 (RAFF-1 [n=565, 2010 – 2012]) at eight and six Canadian EDs, respectively. Sedative choices within and among EDs were quantified, and the risk of adverse events was examined with adjusted and unadjusted comparisons of sedative regimes.
In RAFF-0 and RAFF-1, the combination of propofol and fentanyl was most popular (63.8% and 52.7%) followed by propofol alone (27.9% and 37.3%). There were substantially more adverse events in the RAFF-0 data set (13.5%) versus RAFF-1 (3.3%). In both data sets, the combination of propofol/fentanyl was not associated with increased adverse event risk compared to propofol alone.
There is marked variability in procedural sedation medication choice for a direct current cardioversion in Canadian EDs, with increased use of propofol alone as a sedation agent over time. The risk of adverse events from procedural sedation during cardioversion is low but not insignificant. We did not identify an increased risk of adverse events with the addition of fentanyl as an adjunctive analgesic to propofol.