Factors associated with patient-reported procedural memory following emergency department procedural sedation with ketamine and propofol: A prospective cohort of 563 patients.

OBJECTIVES: To describe the proportion of patients reporting procedural memory following procedural sedation and analgesia (PSA) with ketamine and propofol (KP) administered premixed together (ketofol) or individually (sequential KP) in ED attendees. Identify any clinical or demographic variables associated with procedural memory. METHODS: This was a convenience sample of 563 patients who received KP PSA as per the departmental protocol. A standardised script was used to assess for procedural memory. This was categorised as 'any' and 'unpleasant' prior to discharge (immediate memory) and at telephone follow up (delayed memory). RESULTS: A total of 318 patients had sequential KP and 249 premixed 1:1 ketofol. For sequential KP compared to ketofol, the proportion reporting any memory was as follows: 3.5% versus 3.3% immediate, 4.4% versus 5.5% delayed and 5.4% versus 7.4% for the sum of these. For unpleasant memory, the proportion was as follows: 1.6% versus 2.9% immediate, 1.7% versus 4.7% delayed and 2.2% versus 6.9% all unpleasant memory (odds ratio [OR] 3.3, 95% confidence interval [CI] 1.4-8.1). Memory was associated with male sex (OR 4, 95% CI 1.5-10.5), opiates (OR 3, 95% CI 1.7-7.5), a Wisconsin Sedation Scale score ≥3 (moderate sedation) (OR 4.3, 95% CI 1.1-18.2) and propofol dose <0.75 mg/kg compared to >0.75 mg/kg (13% versus 3%) (OR 6, 95% CI 1.7-21). The ketofol group had 5% (95% CI 0.1-10) more respiratory events requiring intervention. CONCLUSIONS: Procedural memory was uncommon for both mix types; however, a greater proportion of the premixed ketofol group had unpleasant memory. Associations with sex, opiates, moderate sedation and propofol dose were identified, and respiratory adverse events were more common in the premixed ketofol group.

Propofol or Ketofol for Procedural Sedation and Analgesia in Emergency Medicine-The POKER Study: A Randomized Double-Blind Clinical Trial.

STUDY OBJECTIVE: We determine whether emergency physician-provided deep sedation with 1:1 ketofol versus propofol results in fewer adverse respiratory events requiring physician intervention when used for procedural sedation and analgesia. METHODS: Consenting patients requiring deep sedation were randomized to receive either ketofol or propofol in a double-blind fashion according to a weight-based dosing schedule. The primary outcome was the occurrence of a respiratory adverse event (desaturation, apnea, or hypoventilation) requiring an intervention by the sedating physician. Secondary outcomes included hypotension and patient satisfaction. RESULTS: Five hundred seventy-three patients were enrolled and randomized, 292 in the propofol group and 281 in the ketofol group. Five percent in the propofol group and 3% in the ketofol group met the primary outcome, an absolute difference of 2% (95% confidence interval [CI] -2% to 5%). Patients receiving propofol were more likely to become hypotensive (8 versus 1%; difference 7%; 95% CI 4% to 10%). Patient satisfaction was very high in both groups (10/10; interquartile range 10 to 10/10), and although the ketofol group was more likely to experience severe emergence delirium (5% versus 2%; difference 3%; 95% CI 0.4% to 6%), they had lower pain scores at 30 minutes postprocedure. Other secondary outcomes were similar between groups. CONCLUSION: Ketofol and propofol resulted in a similar incidence of adverse respiratory events requiring the intervention of the sedating physician. Although propofol resulted in more hypotension, the clinical relevance of this is questionable, and both agents are associated with high levels of patient satisfaction.

What is the nature of the emergence phenomenon when using intravenous or intramuscular ketamine for paediatric procedural sedation?

OBJECTIVE: Ketamine has become the drug most favoured by emergency physicians for sedation of children in the ED. Some emergency physicians do not use ketamine for paediatric procedural sedation (PPS) because of concern about emergence delirium on recovery. The present study set out to determine the true incidence and nature of this phenomenon. METHODS: Prospective data relating to any emergence agitation, crying, hallucinations, dreams, altered perceptions, delirium and necessary interventions were recorded in consecutive cases of ketamine PPS from March 2002 to June 2007, and analysed. Standard inclusion and exclusion criteria for the use of ketamine were followed. RESULTS: A total of 745 prospective data collection records were available for analysis over the 5 year period. Of all, 93 (12.5%) children cried on awakening when recovering from PPS, 291 (39%) experienced pleasant altered perceptions and 16 (2.1%) experienced what was called 'emergence delirium'. None required any active treatment and all except one settled within 20 min. There was no evidence of an increased rate of nightmares on telephone follow up in the weeks post procedure. CONCLUSION: The belief that ketamine, in the doses used for ED PPS, causes frequent emergence delirium is flawed. A pleasant emergence phenomenon is common, but is not distressing for the child, and has no long-term (up to 30 days) negative sequelae. Rarely, there is anxiety or distress on awakening from ketamine sedation, which settles spontaneously. This should not deter emergency physicians from using ketamine for PPS.

Predictors of emesis and recovery agitation with emergency department ketamine sedation: an individual-patient data meta-analysis of 8,282 children.

STUDY OBJECTIVE: Ketamine is widely used in emergency departments (EDs) to facilitate painful procedures; however, existing descriptors of predictors of emesis and recovery agitation are derived from relatively small studies. METHODS: We pooled individual-patient data from 32 ED studies and performed multiple logistic regression to determine which clinical variables would predict emesis and recovery agitation. The first phase of this study similarly identified predictors of airway and respiratory adverse events. RESULTS: In 8,282 pediatric ketamine sedations, the overall incidence of emesis, any recovery agitation, and clinically important recovery agitation was 8.4%, 7.6%, and 1.4%, respectively. The most important independent predictors of emesis are unusually high intravenous (IV) dose (initial dose of > or =2.5 mg/kg or a total dose of > or =5.0 mg/kg), intramuscular (IM) route, and increasing age (peak at 12 years). Similar risk factors for any recovery agitation are low IM dose (<3.0 mg/kg) and unusually high IV dose, with no such important risk factors for clinically important recovery agitation. CONCLUSION: Early adolescence is the peak age for ketamine-associated emesis, and its rate is higher with IM administration and with unusually high IV doses. Recovery agitation is not age related to a clinically important degree. When we interpreted it in conjunction with the separate airway adverse event phase of this analysis, we found no apparent clinically important benefit or harm from coadministered anticholinergics and benzodiazepines and no increase in adverse events with either oropharyngeal procedures or the presence of substantial underlying illness. These and other results herein challenge many widely held views about ED ketamine administration.

Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children.

STUDY OBJECTIVE: Although ketamine is one of the most commonly used sedatives to facilitate painful procedures for children in the emergency department (ED), existing studies have not been large enough to identify clinical factors that are predictive of uncommon airway and respiratory adverse events. METHODS: We pooled individual-patient data from 32 ED studies and performed multiple logistic regressions to determine which clinical variables would predict airway and respiratory adverse events. RESULTS: In 8,282 pediatric ketamine sedations, the overall incidence of airway and respiratory adverse events was 3.9%, with the following significant independent predictors: younger than 2 years (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.47 to 2.72), aged 13 years or older (OR 2.72; 95% CI 1.97 to 3.75), high intravenous dosing (initial dose > or =2.5 mg/kg or total dose > or =5.0 mg/kg; OR 2.18; 95% CI 1.59 to 2.99), coadministered anticholinergic (OR 1.82; 95% CI 1.36 to 2.42), and coadministered benzodiazepine (OR 1.39; 95% CI 1.08 to 1.78). Variables without independent association included oropharyngeal procedures, underlying physical illness (American Society of Anesthesiologists class >or = 3), and the choice of intravenous versus intramuscular route. CONCLUSION: Risk factors that predict ketamine-associated airway and respiratory adverse events are high intravenous doses, administration to children younger than 2 years or aged 13 years or older, and the use of coadministered anticholinergics or benzodiazepines.

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.

Optimization of propofol dose shortens procedural sedation time, prevents resedation and removes the requirement for post-procedure physiologic monitoring.

OBJECTIVE: To examine the effect of propofol dosing (total dose and number of doses) on patient sedation time and likelihood of resedation. METHODS: This was a prospective, observational patient series in an urban district hospital ED with 42 000 attendances per annum. Patients undergoing an emergent procedure requiring procedural sedation were included. Titrated intravenous propofol was administered according to departmental procedure. Standardized consent and data collection forms were used. Time taken for the patient to become conversational after first administration was recorded and any resedation documented. RESULTS: Four hundred patients, undergoing 404 procedures, were enrolled for the period commencing August 2004 until March 2006. The mean initial propofol bolus was 0.8 mg/kg (SD 0.6), and mean total propofol dose was 1.8 mg/kg (SD 1.0), comprising a mean of 2.3 (SD 2.1) doses of 15.8 mg (SD 11.4). Mean sedation time was 11.8 min (SD 6.9), and increased sedation times were associated with higher total propofol dose and number of boluses (P < 0.0001). Resedation occurred in two patients (0.5%, 95% CI 0-1.6%). CONCLUSION: Shorter sedation times are seen with lower doses of propofol. Patients do not need prolonged post-procedure monitoring because the occurrence of spontaneous resedation associated with propofol use is a rare event. This has implications for patient flow and staff resource allocation in a busy ED.

Do family members interfere in the delivery of care when present during invasive paediatric procedures in the emergency department?

OBJECTIVE: To determine whether family members interfere with patient care when present during invasive procedures performed on their children in the ED. METHODS: A prospective observational study of consecutive cases of procedural sedation of children aged between 12 months and 16 years was conducted between March 2002 and March 2006 in the ED of a secondary-level regional hospital in south-east Queensland. Procedures performed included laceration repair, fracture reduction, foreign body removal and abscess incision and drainage. Parents/primary caregivers were encouraged to stay with their child. A stepwise explanation of the procedure and sedation to be used was undertaken, informed consent obtained and telephone follow up attempted 5-14 days post procedure. RESULTS: Six hundred and fifty-two patient encounters with parents or primary caregivers present for the procedure were included for a total of 656 procedures: 234 laceration repairs, 250 fracture reductions, 85 foreign body removals, 33 abscess incision and drainages, 14 dislocation reductions and 40 other procedures. Telephone follow up was successful in 65% (424) of cases. The mean age was 6.5 years. Family member interference occurred in one case (0.15%, 95% confidence interval 0-0.73%). In 17 cases (2.68%, 95% confidence interval 2.1-5.9%) family members present expressed concerns about the procedure during the telephone follow up but had not interfered at the time of the procedure. There were no significant differences between the concerned parents at follow up and the study group across key patient variables such as child's age (P = 0.369), weight (P = 0.379), respiratory rate (P = 0.477), sex (P = 0.308), procedure indication (P = 0.308) and airway manoeuvres (P = 0.153). CONCLUSION: When family members are encouraged to stay for invasive procedures performed on their child, and careful explanation of the procedure, sedation, possible complications, choice of medication for sedation and possible side-effects is undertaken, family member interference is extremely rare.

Witnessing invasive paediatric procedures, including resuscitation, in the emergency department: a parental perspective.

OBJECTIVE: To determine whether parents prefer to be present during invasive procedures performed on their children in the ED. METHODS: A prospective study using a written survey was carried out in the ED of a secondary level regional hospital in south-east Queensland. The survey conducted between August 2003 and November 2003 consisted of parental demographics, seven theoretical paediatric procedural scenarios with increasing level of procedural invasiveness (including resuscitation) and reasons for the decisions of parents to either stay with the child or leave the room. Parents of children with Australasian Triage Scale (ATS) triage category 3, 4 and 5 were surveyed. RESULTS: Of 573 surveys collected, 553 (96.5%) were completed correctly. The number of parents expressing a desire to be present during a procedure performed on their child was 519 (93.9%) for phlebotomy or i.v. cannulation of an extremity, 485 (87.7%) for nasogastric tube insertion, 461 (83.4%) for lumbar puncture, 464 (83.9%) for urinary catheter insertion, 430 (77.8%) for suprapubic bladder aspiration, 519 (93.4%) during procedural sedation and 470 (85%) during a resuscitation where the possibility existed that their child may die. The most common reason for wanting to be present was to provide comfort to their child (542/98%). The most common reason for not wanting to be present was a parental concern of getting in the way (181/33%). CONCLUSION: Most parents surveyed would want to be present when invasive procedures are performed on their children in the ED. With increasing invasiveness, parental desire to be present decreased. However, the overwhelming majority of parents would want to be in attendance during procedural sedation or resuscitation.

Prolonged pre-procedure fasting time is unnecessary when using titrated intravenous ketamine for paediatric procedural sedation.

BACKGROUND: Paediatric procedural sedation (PPS) is a common procedure in most general EDs. Many departmental guidelines suggest mandatory fasting times for children undergoing PPS, in an attempt to decrease the incidence of postoperative vomiting and (theoretically) aspiration pneumonitis, despite there being little or no evidence in the literature to support these mandatory fasting times. OBJECTIVES: To prospectively address the relationship between preprocedure fasting time and intraprocedure or postprocedure vomiting in children aged 1-12 years undergoing procedural sedation with intravenous ketamine in the ED. METHODS: From January 1999 to May 2000 all children presenting to the Royal Darwin Hospital Emergency Department with a condition requiring ketamine PPS were enrolled for data collection after parental consent was obtained. Titrated intravenous ketamine was administered via protocol. Prospective ED procedural sedation data collection forms of 272 consecutive cases of titrated intravenous ketamine sedation were reviewed. RESULTS: Fasting time was accurately recorded on 257 (95%) data collection forms. There was no intraprocedure vomiting. Overall rate of postprocedure vomiting was 13.9%. No statistically significant association between decreased fasting time and increased incidence of vomiting was found. In fact, there was a trend towards increased incidence of vomiting with increased fasting time (P = 0.08). The rate of vomiting of those children fasted 3 h or greater preprocedure (20/127 or 15.8%) was over twice the rate of those fasted less than 1 hour (2/30 or 6.6%). Incidence of vomiting was significantly associated with increasing age (P = 0.0007). No clinically evident aspiration pneumonitis occurred. CONCLUSION: Prolonged preprocedure fasting time did not reduce the incidence of postprocedure vomiting in this case series; to the contrary there was a increased incidence of vomiting with longer fasting times (P = 0.08). There was an increase in postprocedure vomiting with increasing age of the patients.