Thursday, February 11, 2016

When Procedural Sedation Goes Wrong

Like any typical Emergency Physician, procedural sedation is a frequent part of my practice.  Each procedure, of course, is preceded by discussion of informed consent – the balance of risks, benefits, and alternatives to the procedure.  The risks of many procedures in medicine are, luckily, quite rare – but just how rare are these risks in procedural sedation?

That’s why I love systematic reviews like these – so I can be substantially more precise in such discussions.  Moreso, if you love forest plots – you’ll really love this article.

The high points:
  • Agitation associated with procedural sedation is almost entirely the domain of ketamine, at 16% pooled incidence.  “Ketofol” brings it down to 4.8%, and the remainder are ~1 in 1000.
  • Aspiration was observed once in a pooled multi-agent sample of 2,370 patients.
  • Bradycardia was witnessed essentially only in one study using etomidate – otherwise ~1 in 250.
  • Hypotension is most frequent with propofol, but still only 2%.  The rest fall around 1% or less.
  • Hypoxia was a little harder to pin down, with most agents’ results skewed by outlier studies.  5% is probably reasonable for propofol, while ketamine-containing protocols are probably ~1% or lower.
  • Laryngospasm was witnessed ~1 in 1,500.
It’s worth scanning through their detailed visualizations of their results to get a feel for how different agents compare.  For what its worth, these data general support my practice of using mostly propofol, ketamine, or combinations of each.

“Incidence of Adverse Events in Adults Undergoing Procedural Sedation in the Emergency Department: A Systematic Review and Meta-analysis”
http://www.ncbi.nlm.nih.gov/pubmed/26801209

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