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Procedural Sedation with Propofol for Painful Orthopaedic Manipulation in the Emergency Department Expedites Patient Management Compared with a Midazolam/Ketamine RegimenA Randomized Prospective Study
Ofir Uri, MD1; Eyal Behrbalk, MD1; Amir Haim, MD1; Ehud Kaufman, MD1; Pinchas Halpern, MD1
1 Departments of Orthopedic Surgery (O.U., E.B., A.H., and E.K.) and Emergency Medicine (P.H.), Tel Aviv Sourasky Medical Center, 6 Weitzman Street, Tel Aviv 64239, Israel. E-mail address for O. Uri: ofiruri@gmail.com
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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

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Investigation performed at the Orthopedics Department and the Emergency Medicine Department at the Tel Aviv Sourasky Medical Center, Tel Aviv, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Dec 21;93(24):2255-2262. doi: 10.2106/JBJS.J.01307
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Abstract

Background: 

The use of procedural sedation and analgesia to allow painful orthopaedic manipulations in the emergency department has become a standard practice over the last decade. Both propofol and midazolam/ketamine are attractive sedative regimens for routine use in the emergency department. We hypothesized that sedation with propofol as compared with midazolam/ketamine will save time in the emergency department. The purpose of the present study was to compare the recovery time, the total sedation time, and the adverse events of procedural sedation and analgesia induced with propofol as compared with midazolam/ketamine.

Methods: 

This prospective randomized study was conducted in the emergency department of a tertiary care, university-affiliated medical center. All sedations and orthopaedic manipulations were performed by trained and approved orthopaedic residents assisted by a registered nurse according to the same protocol. Sedation time and adverse events were recorded in real time.

Results: 

Sixty adults (thirty-five men and twenty-five women) with a mean age (and standard deviation) of 45 ± 17 years were randomly enrolled in the study, with thirty patients being managed with each regimen. The average recovery time was 7.8 ± 3.7 minutes following sedation with propofol, compared with 30.7 ± 10.1 minutes following sedation with midazolam/ketamine (p < 0.001). The average total sedation time was 16.2 ± 3.8 minutes for the propofol group, compared with 41.6 ± 10.7 minutes for the midazolam/ketamine group (p < 0.001). The overall rate of respiratory and hemodynamic adverse events was 20% for the propofol group and 10% for the midazolam/ketamine group.

Conclusions: 

The use of propofol for an orthopaedic procedure requiring sedation in the emergency department expedites patient management and saves time in comparison with the use of midazolam/ketamine.

Level of Evidence: 

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Alistair Steel, Consultant Anaesthetist, and James Stimpson, Consultant Anaesthetist
    Posted on June 29, 2012
    Issues around the use of propofol
    Queen Elizabeth Hospital NHS Foundation Trust

    We read with interest the article from Uri and colleagues promoting the use of propofol for painful orthopaedic manipulations in the Emergency Department. (1) We applaud the authors for their attempts to improve patient care and would like to make a number of comments.

     Firstly, propofol has no analgesic properties. Whilst propofol will ablate the response to painful stimuli, the depth of sedation required to do this will inevitably lead to loss of airway protection, reduced respiratory drive and cardiovascular instability. The doses of propofol used in the study approximate those used for induction of anaesthesia; therefore it is surprising that only one in five patients experienced an adverse event. The adverse events as described read as a worrying strategy; that a desaturation to less than 90% could potentially be left for longer than 60 seconds without any attempt to improve it other than airway repositioning seems to suggest to the greater emergency medicine community that this is a reasonable action when, in the context of induction of anaesthesia, any desaturation below 90% should trigger immediate and sustained attempts to reaffirm and maintain the airway. Likewise, apnoea of greater than 20 seconds responding to airway repositioning suggests airway obstruction, not absence of respiratory drive. Both of these adverse events suggest that the dosage of drug delivered is in excess of sedation, and has delivered anaesthesia. The described loss of airway reflexes is something that has been extensively explored and managed by the anaesthetic community, and what a large part of anaesthetic management consists of. The combination of this, with inadequate starvation duration, in patients with traumatic injury (and can therefore be assumed to have a full stomach), leaves both patient groups susceptible to reflux of gastric contents and aspiration, a condition associated with a high mortality.

    Analgesia is required for painful procedures; indeed relief from pain may be considered to be a basic human right.(2) The addition of analgesia is not only ethically required, but will reduce the amount of sedation required and may make the overall experience more acceptable to the patient. In addition, appropriate pain management may facilitate early post-procedural rehabilitation (particularly in the case of shoulder relocation), reduce the ongoing need for strong analgesic use, and may help to reduce the transition from acute to chronic pain mechanisms. A short acting opioid such as fentanyl or alfentanil together with intravenous paracetamol would be suitable for these purposes.

    We agree that propofol has more appropriate pharmacological properties for these types of procedures than midazolam. However, intermittent boluses of propofol, when given by the same clinician performing a procedure, is likely to result in poor operator satisfaction and lead to an increase in adverse events. A target-controlled infusion of propofol (TCI) is less likely to lead to overdosage, airway obstruction and apnoea, will reduce the total dose of drug further, and is a relatively safer and more practical way of sustaining the levels of sedation required. (3)

    Secondly, we note that capnography was not used for monitoring, as mentioned in the discussion. It is likely that the true incidence of respiratory depression and airway obstruction was significantly greater than that observed by the authors, particularly as the definition of adverse events required such prolonged timings. The ‘real-time’ monitoring of pulse oximetry lags approximately 30 seconds behind the drop in arterial haemoglobin saturation, thus likely further increasing the true incidence of respiratory depression and airway obstruction that went unidentified. The Association of Anaesthetists of Great Britain & Ireland recommend that capnography be applied to all patients undergoing deep sedation.(4) The recent National Audit Project 4 (NAP4) concluded that the absence of capnography, or the failure to use it properly, contributed to 50% of deaths from airway complications in the emergency department. (5) High standards of monitoring, including capnography, should be used for these high-risk patient groups.

    Thirdly, three months of Intensive Care training is unlikely to provide the necessary airway skills to manage a patient with airway difficulties, and the technical ability to intubate the trachea is only one of the many competences required to safely care for a deeply sedated or anaesthetised patient. Assessments for predicting a difficult airway are notoriously insensitive and the ability to safely manage sedated patients with all the complications that might arise takes several years of anaesthetic training (6).

    Finally, the authors might consider the greater use of regional anaesthesia techniques for performing painful procedures in the Emergency Department. The use of regional anaesthesia results in less time spent in the Emergency Department and less one-on-one health care provider time compared to those receiving procedural sedation, facilitating early discharge and with high levels of patient satisfaction.(7)

    References
    1) Uri O, Behrbalk E, Haim A, Kaufman E, Halpern P. Procedural Sedation with Propofol for Painful Orthopaedic Manipulation in the Emergency Department Expedites Patient Management Compared with a Midazolam/Ketamine Regimen: A Randomized Prospective Study. Journal of Bone & Joint Surg.  2011; 93:2255-62 

    2) Brennan F, Carr D and Cousins M. Pain Management: A Fundamental Human Right. Anesth Analg 2007;105:205-21

    3) Newson C, Joshi GP, Victory R, White PF. Comparison of Propofol Administration Techniques for Sedation During Monitored Anesthesia Care. Anesth Analg 1995;81:486-9   

    4) Safety Statement - The use of capnography outside the operating theatre. Association of Anaesthetists of Great Britain & Ireland (AAGBI), 2011                          

    5) Report and findings of the 4th National Audit Project. Royal College of Anaesthetists UK, 2011

    6) Curriculum for a CCT in Anaesthetics. Royal College of Anaesthetists UK, 2010

    7) Blaivas M, Adhikari S, Lander L. A prospective comparison of procedural sedation and ultrasound-guided interscalene nerve block for shoulder reduction in the emergency department. Acad Emerg Med. 2011;18:922-7.

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