Profiling adverse respiratory events and vomiting when using propofol for emergency department procedural sedation.

OBJECTIVES: To evaluate the rate of adverse respiratory events and vomiting among ED patients undergoing procedural sedation with propofol. METHODS: This was a prospective, observational series of patients undergoing procedural sedation. Titrated i.v. propofol was administered via protocol. Fasting status was recorded. RESULTS: Four hundred patients undergoing sedation were enrolled. Of these 282 (70%, 95% confidence interval [CI] 66-75%) had eaten or drunken within 6 and 2 h, respectively. Median fasting times from a full meal, snack or drink were 7 h (interquartile range [IQR] 5-9 h), 6 h (IQR 4-8 h) and 4 h (IQR 2-6 h), respectively. Overall a respiratory event occurred in 86 patients (22%, 95% CI 18-26%). An airway intervention occurred in 123 patients (31%, 95% CI 26-35%). In 111 cases (90%, 95% CI 60-98%) basic airway manoeuvres were all that was required. No patients were intubated. Two patients vomited (0.5%, 95% CI 0.0-1.6%), one during sedation, one after patient became conversational. One patient developed transient laryngospasm (0.25%, 95% CI 0-1.2%) unrelated to vomiting. There were nil aspiration events (0%, 95% CI 0-0.74%). CONCLUSIONS: Seventy per cent of patients undergoing ED procedural sedation are not fasted. No patient had a clinically evident adverse outcome. Transient respiratory events occur but can be managed with basic airway interventions making propofol a safe alternative for emergency physicians to provide emergent procedural sedation.

Profiling patients suspected of drug seeking in an adult emergency department.

OBJECTIVES: (i) To profile ED consultations where drug seeking is considered; (ii) to clarify if an Australian patient cohort shares the characteristics identified in the literature, that is, high rate of psychiatric, chronic pain and drug dependency problems; and (iii) to quantify the extent of missed organic disease in suspected drug-seeking presentations. METHODS: Prospective descriptive study with an initial enrolment period of 3 months, follow up at 3 and 5 years. Tertiary hospital ED doctors voluntarily identified suspected drug-seeking behaviour. Patients' demographic information, past history, presenting features, investigations, management and missed diagnoses of organic pathology were collected. Recurrent presentations of drug seeking, self-harming, psychiatric, chronic pain and drug dependency complaints were documented. RESULTS: Thirty-seven presentations (31 patients) of 10,958 total attendances were analysed. All patients were less than 65 years. Twenty-one patients (68%, 95% confidence interval [CI 49.7-85.8]) were on unemployment or disability pension. Twenty-six presentations (70% [95% CI 54.2-86.3]) described psychiatric problems, whereas three presentations (8% [95% CI 0.0-18.3]) had chronic pain and 10 presentations (27% [95% CI 11.4-42.7]) had drug dependency problems. Twenty-six patients (84% [95% CI 69.3-98.4]) recurrently presented with self-harming and drug-seeking behaviour at 3 years. The risk of missing organic pathology was 8/37 (22% [95% CI 7.0-36.2]). CONCLUSIONS: Further characterization of this population would help accurate diagnosis of this aberrant behaviour and decrease the risk of missing organic pathology. The management of frequently presenting patients should prompt formulation of departmental plans to effectively assess and manage these people.

Diagnosing drug-seeking behaviour in an adult emergency department.

OBJECTIVE: The objective of the present study were to determine factors used by ED doctors to diagnose drug seeking and their attitude towards management of this patient group. METHODS: Prospective, descriptive study, of doctors working in a tertiary hospital ED. Doctors voluntarily identified patients they suspected were drug seeking and completed a written survey. RESULTS: Thirty-seven surveys were completed for presentations involving 31 patients. A patient's specific request for narcotics, previous documented episodes of suspected drug seeking, an unwillingness to try simple analgesia and demanding or aggressive behaviour were the most frequently used factors for diagnosing drug seeking. These factors are similar to, but not the same, as the criteria in the literature. Doctors commonly found consultations involving drug seeking to be unsatisfying. CONCLUSIONS: Factors, such as those used by doctors in the present study, should not be used as diagnostic markers. Further study is warranted in order to improve the effectiveness of consultations involving drug seeking.